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HX64062252 


A  resume  of  surgical 


RECAP 


, 


A  resume  of  sur^ial  operations  from  A- ■-. 
1,  1592  to  April  1,  1093  '  ice  of 

Dudley  ,   !  len* 


TPD34- 


N4-t 


mtljeCttpofltogork 

COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/resumeofsurgicalOOnevi 


A    RESUME 


Surgical  Operations 


From  April  1,  1892,  to  April  1,  1893, 


IN  THE  PRACTICE   OP 


Dudley  P.  Allen,   M.  D., 

VISITING    SURGEON    TO 
LAKESIDE    AND    CHARITY    HOSPITALS,     CLEVELAND,     OHIO. 

PRESIDENT   OF  THE   OHIO   STATE   MEDICAL   SOCIETY. 


By  WILLIAM  H.   NEVISON,  M.  D., 
Assistant  to  Dr.  Allen. 


A  RESUME  OF  THE  SURGICAL  OPERATIONS  IN  THE 
PRACTICE  OF  DUDLEY  P.  ALLEN,  M.  D., 

VISITING     SURGEON     TO      LAKESIDE;      AND     CHARITY      HOSPITALS, 

CLEVELAND,  OHIO. 

PRESIDENT    OF    THE    OHIO    STATE    MEDICAL    SOCIETY. 

From  April  i,  1892,  to  April  1,  1893. 


By  WILLIAM  H.  NEVISON,  M.  D. 

Assistant  to  Dr.  Albn. 


Having  been  assistant  to  Dr.  Allen  during  the  past  year  and 
having  witnessed  in  his  practice  a  number  of  operations  of  more 
than  usual  interest,  it  occurred  to  me  to  publish  a  resume  which 
would  include  the  surgical  operations  performed  by  him  during  the 
above  period. 

To  accomplish  this,  it  has  seemed  best  to  tabulate  certain 
portions  of  the  work,  giving  as  briefly  as  possible  the  interesting 
points  in  connection  with  each  case,  and  in  addition,  to  give  some- 
what in  detail  a  few  of  the  more  important  cases 

The  method  of  classification,  with  the  exception  of  "  Tumors 
not  Abdominal,"  has  been  carried  out  according  to  the  anatomical 
field  of  operation  ;  the  sub-divisions  for  the  most  part  according  to 
the  pathological  conditions  found. 


The  following  is  a  summary  of  the  operations  in  the  order  in 
which  they  have  been  considered: 

Operations  upon  the  abdomen 62 

Operations  for  tumors  (not  abdominal)  51 

Operations  upon  the  genito-urinary  organs 46 

Operations  upon  the  rectum  and  anus 17 

Operations  upon  the  chest 8 

Operations  upon  the  head  and  neck 22 

Operations  upon  the  upper  extremities  26 

Operations  upon  the  lower  extremities 32 

Miscellaneous  operations 10 

Total  number  of  operations 274 


OPERATIONS  UPON  THE  ABDOMEN- 

62  operations.  Of  this  number,  49  were  laparotomies  and  13 
were  operations,  including  hernica  and  kidney  cases,  and  cannot, 
strictly  speaking,  be  called  laparotomies.  This  number  includes 
but  one  incomplete,  the  remaining  being  all  completed  operations. 

The  laparotomies  include  the  following: 

15  operations  for  appendicitis  ;  12  for  cystic  diseases  of  the 
ovaries  ;  8  oophorectomies  and  salpingectomies;  5  for  fibroids  of 
the  uterus ;  2  for  extra-uterine  pregnancy  ;  3  for  pelvic  abscess  ; 
1  for  pancreatic  cyst ;  1  for  volvulus  of  the  ileum;  1  for  foreign 
body  and  1  incompleted  operation  for  impacted  gall  stone. 

PREPARATION  OP  THE  PATIENT  AND  DETAILS  OF    OPERATION. 

When  opportunity  afforded  the  patient's  bowels  were  moved 
with  ol.  ricini  the  day  before  the  operation,  and  an  injection  and 
movement  the  morning  of  operation.  A  thorough  bath  was  given 
the  evening  before  and  a  moist  bi-chloride  dressing  applied  over 
the  field  of  operation.  After  the  patient  was  under  the  anaesthetic, 
the  parts  were  shaved  and  again  thoroughly  scrubbed  and  cleansed 
with  ether  and  lastly  bi-chloride  solution. 

Ether  was  used  as  anaesthetic  in  all  cases  unless  contra- 
indicated  by  lung  or  kidney  complications. 

The  instruments,  towels,  operating  gowns  and  dressings  were 
sterilized,  just  before  using,  by  raising  to  a  high  temperature  for 
half  an  hour.  Sponges  were  put  through  solutions  of  permanganate 
oi  potash  and  sulphurous  acid  and  kept  until  used  in  carbolic 
solution. 

During  the  operation,  sponges  and  instruments  were  kept  in 
distilled  water  and  no  antiseptic  solutions  were  used. 

Cat-gut  ligatures  were  prepared  by  placing  for  a  few  hours  in 
bi-chloride  solution  and  preserving  in  alcohol  and  juniper  oil. 

Silk  was  boiled  in  carbolic  solution  and  kept  in  a  solution  of 
the  same. 


Silkworm-gut  sutures  were  washed  in  bi -chloride  solution  just 
"before  the  operation. 

Distilled  water  was  used  for  irrigation. 

The  hands  of  operator  and  assistants  were  well  scrubbed  and 
put  through  solutions  of  permanganate  of  potash,  sulphurous  acid 
and  bi-chloride  of  mercury. 

The  temperature  of  the  room  operating  was  kept  at  about 
75°,  and  the  limbs  of  the  patient  wrapped  in  flannel  with  hot  water 
bottles  at  the  sides  if  needed. 

In  many  operations  the  Trendenleburg  position  was  used  to 
great  advantage  when  difficult  pelvic  dissections  were  to  be  made. 

Cat-gut  was  used  for  adhesions  and  heavy  silk  for  the  litigation 
of  pedicles  The  abdominal  incisions  were  closed  with  silkworm- 
gut  sutures,  taking  care  to  include  all  the  layers  of  the  abdominal 
wall. 

After  the  operation,  patient  received  nothing  by  stomach  until 
all  feelings  of  nausea  were  passed  and  were  then  allowed  small 
quantities  of  water,  and  later,  milk  and  lime  water. 

The  intense  thirst  was  often  much  relieved  by  rectal  injections 
of  warm  water  and  stimulants. 

Morphine  was  allowed  only  when  patients  suffered  severe  pain. 
Bromide  and  chloral  was  given  by  rectum  for  sleeplessness. 

The  bowels  were  first  moved  by  small  and  repeated  doses  of 
hydrarg  chlor.  mit,  followed  by  Rochelle  and  injections.  In  several 
cases  when  symptoms  of  obstruction  were  present  and  patients 
could  not  retain  mcdicines  given  by  stomach,  very  satisfactory 
results  were  obtained  by  rectal  injections  of  ol.  ricini  and  aloes. 


if} 

OS 
03 

Was  in  ex- 
tremis at  time 
of  operation 
and  never 
reacted. 

Vomiting  con- 
tinued    after 
operation. 
Could      obtain 
no  movement. 
Patient  gradu- 
ally failed. 
Autopsy  show- 
ed the  tampon 
in  place;  ex- 
tending down 
to  appendix. 

Z      _ 

03 

Death 

in 

Hi 
hours. 

Death 

in 

23 
hours. 

%      -     -"      & 

a,      •—      ,--       * 

Appendix 

and 
Concretion. 

Appendix   im- 
pacted    and 
perforated 
near    base.  — 
Ligated    and 
removed. 

No  concretion. 

Appendix 

gangrenous 
and  perforat- 
ed at  base. 
Ligateil     and 
removed. 

No  concretion. 

Appendix  per- 
forated at 
base;      con- 
tained 4  eon 
cretions. 

Ligated  and 
removed. 

| 

Abdominal  cavity 
full  of  pus. 

Irrigated  and   in- 
troduced    Miku- 
licz tampon. 

Abdominal  cavity 
contained    freces 
and  pus. 

1  r  ri  gated     and 
drained     with 
glass  lube  in  Mi- 
kulicz tampon. 

Objective 
Symptoms. 

Excessive  tym- 
panites; constip- 
ation for  54  hours 
before  operation. 

Temperature  loi 
evening  b  e  f o re 
operation;  only 
time  at  which 
there  was  any 
fever. 

E  x  c  e  s  s  i  v  e  tym- 
panites; constip- 
ation   and    ster- 
coraceous  vomit- 
ing for  48   hours 
before  operation. 

l<)  x  c  e  s  s  i  v  e  tym- 
paintes;    slight 
dullness      o  v  e  r 
caecum. 

>     = 

Gener'I  abdominal 
pain  most  severe 
in  region  of  um- 
bilicus.      ft 

General      abdom- 
inal pain;    never 
localized. 

«  —  S 

13  S  C 

o 
■Jl 

5 

a3 

>        Z 

History  of 
lirevious 
Attacks. 

3 

o 

z 

Stage  in 

which 

Operated. 

Acute. 
3  days. 

Acute. 
4  days. 

Acute. 
2  days. 

Date  and 

Place  of 

Operation. 

July   1, 
1892. 

Charity 
Hospital. 

July  13, 
1892. 

Charity 
Hospital. 

Sept.  17, 

1892. 

Residence. 

In  Con- 
sultation 
with 

<     5 

—    a."    -A 

"    at    a, 

5                                    ?? 

Boh. 

27 

Male. 

4                                     oi 

£ 

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III 

W.E.S. 

o 


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i— i 

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Q 
£ 
W 
Ph 

Pm 

« 

o 
ft 

GO 
O 

« 
Pm 

•o 


Uninterrupted 
recovery. 

Entirely  heal- 
ed in  about 
4  weeks. 

6e 

a     o 

a     a 

13        _ 

r    2 

.5     ° 

>      — 

3 

V3 

pi 

T5                                   02 

03       ■*■<        C-J        < 

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« 

Appendix 

and 

Concretions. 

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13  f3  ao  t» 

Slii; 

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a  «3  a:  i;ss 
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o     & 

SJ 

History  of 

previous 

Attacks. 

to 
"2     k            «     tn     u 

*        «       ^       «        fl        O        B 

a  a  -  a  a  |  - 

03  o  Ai  -  3  -»  1<  -S  ""  ^    • 

ffil^|-=-252M^ 

03 
3 

Stage  in 

which 

Operated. 

5                         s3 

S3                          -a 

<             t~ 

a                   s3 
S3                 -a 

o5                        &o 

3                              S3 
S3                               a! 

Date  and 

Place  of 

Operation. 

03 

o                    2 

PCI 

03 
S3 

lc      .               a 
3    S              2 

'"S                                         03 

43 

H*                                               S3 

>>        oi                a: 

In  Con- 
sultation 
with 

yl        t       «          g        -2 

ft            "< 

M      *             a       . 
•      2             o    '  ® 

ft  3       < 

ft      as             a" 

o     -2     *-     E     -a 
•     kS     «     4     5 
^      r5              a:     O 
ft                      O 

**   <c  "J 

s   «  J 
iz;  <!  cc 

O                           CO                           p^ 

a                             a! 

6 

QQ 

m                 03 

Entirely 
healed  in 
about  six 
weeks;  has 
had  no  sub- 
sequent 
trouble. 

General  peri- 
tonitis devel- 
oped :    autop- 
sy showed  no 
pus  in  abdom- 
inal cavity: 
everything 
pertaining  to 
operation    in 
perfect  order. 

Autopsy  show- 
ed general 
peritonitis 
with  collec- 
tion of  pus  in 
trout  of 
bladder. 

Appendix  was 
perforatad 
and  in  a  mass 
of  adhesions. 

rt 

Death 

in 
4  days. 

Death 
in 

days. 

Appendix 
perforated 
near  base; 
ligated  and 
removed. 

No  concretion. 

Appendix; 
perforated 
near  baset 
ligated  and 
removed. 

Concretion 
size  of  a  split 
pea. 

Appendix  not 
found. 

Xo  concretion. 

Abscess    cavity 
containing  quart 
of  pus;  appendix 
constricted  some- 
what in  the  mid- 
dle as  though 
from    a    scar  re- 
maining after 
former  inflamma- 
tion. 

Iodoform   gauze 
tampon. 

Abcess  cavity  con- 
taining   about   3 
oz.  pus,  had  dis- 
sected into  pelvis 
along  side  of  rec- 
tum. 

Iodoform  gauze 
tampon. 

Small    abscess: 
gangrenous  plac- 
ed on  anterior 
surface  of  caecum 
size  of  a  dollar. 

Iodoform    gauze 
tampon. 

Well  marked  dull- 
ness  and    indur- 
ation around  cae- 
cum. 

Temperat're  102^. 

Considerable  tym- 
panites. 

Very  tympanitic; 
dullness  over  cae- 
cum. 

Highest  temp.  102. 

Vomited  and  bad 
chills       during 
evening  be  for  e 
operation. 

Excessive       tym- 
panites. 

No   dullness  over 
caecum. 

Could    make    out 
nothing  by  palp- 
ation. 

Temp.  101. 

0  03  ,£ 

~  —  e 

««     'fit 

■gftS 

General      abdom- 
inal pain,    local- 
ized on  2d  day.— 
Pain  was  extreme 
requiring  fre- 
quent    hypoder- 
mics of  morphia. 

General      abdom- 
inal pain ;    more 
tenderness  in  2d 
day  over  caecum. 

03        3 
>        03 

o     & 

Over 
caecum. 

%     1 

S3 

o5 
o 

03 

3 

S5 

03 

a 
o 

Acute. 
5  days. 

03                                                 p, 

°                                               Si 
CM 

Acute. 
2%  days. 

Oct.  10, 

1892. 

Residence. 

Feb.  8. 
1893. 

Residence. 

Feb.  19, 
1893. 

Residence. 

Dr.  C.  D. 
Noble 

of 

Oberlin, 

Ohio. 

Dr.  C.  D. 

Noble 

of 

Oberlin, 

Ohio. 

Dr.  T.  M. 

Sabin 

of 

Warren, 

Ohio. 

J                                        33 

5,      a.      | 

_•                         ^ 

~                     CM                      03 

<                                              3 

<                                 pen 

VIII 

E.  H. 

IX 

F.E.C. 

a 

X 

3 
P3 

Given  in 
detail  below. 

Entirely 
healed  in 
about  seven 

weeks. 

"■"      a; 
33 

Result. 

rt 

Pi 

tf 

Appendix 

and 
Concretion. 

Appendix 
could  not  be 
found. 

Concretion 
size  of    hick- 
ory nut. 

Appendix  per- 
forated   near 
base  and 
filled  with    a 
granulation 
tissue;    ligat- 
ed  and  re- 
moved. 

No  concretion. 

Appendix  not 
found. 

No  concretion. 

3 

4) 

Numerous     small 
abscesses  and 
sinuses    dissect- 
ing toward  liver; 
caecum  in  a  mass 
of  adhesions. 

Tamponed    with 
iodoform  gauze- 

Numerous  sinuses 
leading  to  the 
appendix    which 
was    located   be- 
hind the  caecum. 

Iodoform   gauze 
tampon. 

Small   abscesses 
connected  by  sin- 
uses; caecum  in  a 
mass  of  adhes- 
ions; patient  too 
weak    to    endure 
prolonged     oper- 
ation. 

Gauze  tampon. 

03        W 

>     a 
S     3 

O          4^ 

03        ft 

!o     S 

O       P» 

Under    an    anaes- 
thetic  dullness 
and  resistance  in 
caecum  region. 

Dullness   and   re- 
sistance     over 
caecum ;    could 
not  make   out  a 
clearly     defined 
tumor. 

.'Z   3, 
_  > 

15*3  a 

=  23 
a3* 

Q.«0 

>     a 
a     £, 

OD      CO 

Pain  over  caecum 
during  attacks. 

Always  slight 
tenderness    on 
deep  pressure. 

Constant  pain  in 
region  of  caecum, 
greatly  increased 
during  attacks. 

1st  attack,  Aug. '91 

2  "       Feb. '92 

3  "        Apr.'92 
From  this  time 

confined    to    bed 
until  operation. 

During   1st    week 
severe  pain  over 
caecum. 

Te  n  d  em  ess  re- 
maining and   ag- 
gravated by 
sliglitest  effort  to 
get  around. 

O 

'3 

Right 
linea 
semilun- 
aris. 

Right 

linea 

semilun- 

aries. 

Over 
caecum. 

History  of 
previous 
Attacks. 

Repeated 

attacks 

during 

last  five 

mouths. 

3  severe 
attacks 
during 

last  five. 

months. 

Severe 
attack 
several 
weeks  be- 
fore and 
since  then 
severe 
pain  at 
intervals. 

Stage  in 

which 

Operated. 

3 
•- 

o 

3 

.a 
o 

3 

Date  and 

Place  of 

Operation. 

May  12, 

1892. 

Charity 
Hospital. 

July  2, 
1892. 

Charity 
Hospital. 

Sept.  19, 
1892. 

Lakeside 
Hospital. 

Tn  Con- 
sultation 
with 

Dr.  F.  W. 

Upson, 

Conneaut, 

Ohio. 

1-5 

p-th       oj 
l—l         a; 

p 

Dr.  M. 

Borts. 

Nat., 

Age, 
Sex. 

<       s       3 

a          -           S 

«                 CM                  <B 

Ger. 

26 
Male. 

d 
ft 

►4 

X             d 
6 

XII 

c.  s. 

Entirely 
healed  in 
1  weeks. 

Left  hospital 

Feb.  Uth, 
wound  entire- 
ly healed, 
with  excep- 
tion of  a  few 
of  granula- 
tion. 

Healing  In- 
first 

intention. 

Left 
Hospital 

Feb.  25th. 

<A 

e4 

<& 

Appendix  per- 
forated       i  n 
middle      and 
filled     with 
granulatio  n 
tissue. 

No  concretion. 

X 

pendix  found 
with    concre- 
tion in   open 
end. 

A  in  i)  u  t  a  t  e  d 
and    sewed  0- 
pening     with 
cat-gut. 

Gauze  tampon 

App'ndix  free. 
Constriced  at 
base:       con- 
tained 3   con- 
cretions: mu- 
cous    m  e  m  - 
brane     ulcer- 
ated. 

No  abcess;  appen- 
dix posterior   to 
caecum  and  close- 
ly adherent;  dis- 
sected    off     and 
sewed  with    fine 
silk,     inverting 
the  stump;  gauze 
tampon. 

Sinuses  leading  to 
to  appendix. 

Gauze  tampon. 

No   sign    of    pre- 
vious   peritoneal 
i  n  fl  a  m  m  ation: 
amputated       ap- 
pendix;      sewed 
with     fine     cat- 
gut;   closed    ab- 
dominal    wound 
entirely. 

Under     anaesthe- 
tic:   no  dullness; 
no  tumor;    slight 
resistance  on, 
deep  pressure. 

Dullness  and  fistu- 
lous op'ning  from 
previous  oper- 
ation. 

X     . 
X  — 

a.  ~ 

■5 

c  ZZ 

Pain  over  caecum 
during  attacks. 

Tenderness  on 
pressure    at    all 
times. 

-*  X 

H 

Pain  over  caecum 
during  attacks. 

No  tenderness 
after    a  c  u  t  e 
symptoms   had 
passed. 

a,      2 
>      o 
O      | 

S-        £ 

>      o 

°    § 

Zj       3 

>     5 
©     & 

3  attacks 
in  last 

six 
months. 

attacks 

during 

last 

tliree 

years. 

About 

2  attacks 

yearly 

during 

last  10  or 

12  years. 

6 

3  t 
o 

d 

'3 

o 

Sh 

o 

© 

Sh 

o 

Dec.  3, 
1892. 

Charity 
Hospital. 

Jan.  17, 
1893. 

Charity 
Hospital. 

Jan.  30, 
1893. 

Lakeside 
Hospital. 

Dr.  G.  A. 
Ashmun 

and 

Dr.  F.  J. 

Bauer 

of 

Mogadore. 

ft    6 

■                         a3 

1                        8 

E                 CO                 72 
J5                 M                 ,| 

j         S          1 

■^                                tin 

XIII 
W.C.  L, 

XV 

T.  S.  T. 

IO 

The  above  cases  have,  as  a  matter  of  convenience,  been  grouped 
in  three  sub-divisions. 

FIRST   SUB-DIVISION. 

The  first  includes  three  acute  cases  in  which  perforation  took 
place  into  the  abdominal  cavity  before  the  operation,  causing  general 
suppurative  peretonitis.     All  three  cases  died 

Case  I  and  II  had  no  local  symptoms  pointing  to  the  appendix, 
and  although  appendicitis  was  suspected,  still  it  was  deemed  best  to 
make  the  median  incision  in  order  to  reach  all  possible  causes  of 
obstruction. 

Case  III  is  worthy  of  mention  in  detail,  as  follows: 

Patient  a  strong  muscular  man,  always  had  good  health.  Was 
perfectly  well  until  the  morning  of  Sept-  loth,  when  he  ate  a  light 
breakfast  and  complained  of  a  tired  feeling.  Had  a  good  move- 
ment after  breakfast  and  went  to  his  office.  At  2  p.  m.  felt  badly; 
went  home;  vomited  and  went  to  bed  complaining  of  general 
abdominal  pain.  Dr.  Ashmun  was  called  about  5  p.  m.,  found  no 
rise  of  temperature;  pulse  72;  gave  powders  of  morphia. 

Sept.  16th  Morning  temperature  100)4,  pulse  84,  no  vomiting, 
no  pain,  gave  powders  of  hydrarg.  chlor.  mit.  ipecac  and  soda. 
Early  in  morning  had  slight  chills  Passed  a  very  comfortable 
day,  and  at  10  p.  m.  was  suddenly  taken  with  severe  general 
abdominal  pain.  Anodynes  were  given  and  hot  fomentations 
applied  to  the  abdomen. 

Sept.  17th  Morning  temperature  100)4,  puLe  84.  Drs.  Allen 
and  H.  K.  Cushing  were  called  in  consultation  and  it  was  decided 
to  operate.  At  2  p.  m  ,  temperature  102)4,  pulse  98  Patient 
suffering  most  extreme  pain,  controlled  Only  by  large  hypodermics 
of  morphia  Operation  at  5  p.  m  Incision  over  caecum;  abdominal 
cavity  full  of  pus  The  appendix  was  located  to  the  outer  and 
lower  border  of  the  caecum,  and  no  adhesions  were  formed. 
Appendix  had  perforated  near  its  base  and  contained  three  concre- 
tions;   was  removed  and   the  stump    sewed  with    fine  oilk.     The 


abdominal  cavity  was  flushed  with  several  gallons  of  boiled 
water.  A  rubber  drainage  tube  and  Mikulicz  tampon  were  intro- 
duced through  the  abdominal  incision  into  the  pelvis  and  a  second 
drainage  tube  carried  through  a  counter  opening  at  the  edge  of  the 
quadratus  lumborum  in  the  right  flank.  Pulse  after  operation, 
124.     Patient  passed  a  comfortable  night. 

"  Sept.  18th.  Morning  temperature  101$,  pulse  99;  external 
dressings  changed  without  disturbing  tubes  and  tampon  During 
afternoon  gave  small  doses  of  hydrarg.  chlor.  mit.  until  one  grain 
was  taken,  and  followed  by  teaspoonful  doses  of  Rochelle  salts.  At 
10  p  m.  gave  an  enema  and  obtained  a  passage  containing  lumps 
of  faecal  material-     Passed  a  restless  night. 

Sept.  19th.  Morning  temperature  100}4,  pulse  99.  Portion  of 
gauze  tampon  was  removed.  Evening  temperature  101  f,  pulse 
104.     Gave  Rochelle,  but  obtained  no  movement. 

Sept.  20th.  Morning  temperature  100,  pulse  110.  Patient 
very  tympanitic.  Tampon  was  removed  and  Rochelle  repeated 
during  the  day.  At  5  p.  m.  patient  was  in  a  bad  condition.  The 
abdomen  being  greatly  distended,  an  opening  was  made  in  a  loop 
of  the  intestine  presenting  at  the  bottom  of  the  wound  and  three 
pints  of  thin  faecal  material  were  withdrawn,  together  with  the 
passage  of  considerable  flatus.  The  patient  was  greatly  relieved 
and  passed  a  comfortable  night.  Was  given  milk  and  lime  water 
by  stomach,  and  injections  of  whiskey  and  water  by  rectum. 

Sept.  21st.  Morning  temperature  101  j£,  pulse  98.  The  wound 
was  irrigated  every  two  hours  and  the  discharge  of  faecal  material 
continued. 

Sept.  22d.  About  noon  had  a  sinking  spell,  but  revived  under 
hypodermics  of  strychnia  and  enemata  of  digilalis,  whiskey  and 
water.  At  2  p.  m  had  another  spell;  the  extremities  became  cold 
and  the  patient  gradually  failed  and  died  at  midnight. 

Autopsy  16  hours  after  death;  there  was  faecal  material 
throughout  the  lower  part  of  the  abdominal  cavity  with  pus  along 


12 

the  under  surface  of  the  liver.  The  puncture  in  the  gut  had  been 
made  in  the  ileum  about  12  inches  from  the  ileo-caecal  valve  and 
five  inches  above  this  spontaneous  perforation  had  occurred  into 
the  peritoneal  cavity.  Adhesions  had  formed  around  the  point  of 
puncture  and  no  infection  of  the  abdominal  cavity  had  taken  place 
from  this  source  The  sutures  in  the  stump  of  the  appendix  were 
in  place  and  the  opening  was  occluded.  The  ileum  near  its 
entrance  into  the  caecum  was  tightly  compressed  by  the  tympanitic 
intestines  against  the  brim  of  the  pelvis  which  had  caused  obstruction. 
Great  tympanites  and  pain  had  resulted  from  this  obstruction 
Death  was  caused  by  sepsis 

SECOND    SUB-DIVISION. 

The  Second  subdivision  includes  six  acute  cases  with  circum- 
scribed abscesses,  with  three  deaths  and  three  recoveries,  the  cause 
of  death  in  all  three  cases  being  due  to  the  extension  of  inflammation, 
resulting  in  general  peritonitis.  The  following  cases  are  worthy  of 
particular  mention: 

Case  V. — M.  S-  Was  a  delicate  woman,  lately  having  been 
confined.  After  the  operation  the  patient  did  not  react  well,  and 
vomited  almost  incessantly.  On  second  day  attempted  to  obtain 
movement  of  the  bowels  by  small  and  repeated  doses  of  Rochelle 
salts.  The  gauze  tampon  was  removed  and  large  injections  of 
water  given  by  rectum,  but  no  movement  could  be  obtained.  The 
patient  gradually  failed,  and  died  sixty  hours  after  the  operation. 
Autopsy  on  the  following  day  showed  peritonitis  with  an  accumu- 
lation   of  purulent  fluid  in  the  peritoneal  cavity. 

Case  VI. — H.  B.  A  delicate  boy  8  years  of  age.  At  the 
operation  the  abscess  was  found  to  have  burrowed  into  the  pelvis 
along  the  side  of  the  rectum  After  the  operation  the  patient  re- 
acted well  and  went  along  nicely  for  the  first  two  days.  On  the 
third  day  developed  a  severe  cystitis.  Urine  contained  albumen 
and  considerable  pus.  Patient  complained  of  great  pain  in  pelvis, 
accompanied  by  some  rise  of  temperature  and  pulse.     The   tampon 


J  3 

was  removed  and  cavity  thoroughly  irrigated.  This  was  followed 
by  a  fall  of  temperature  to  99,  and  patient  went  on  to  recovery. 
The  wound  was  entirely  healed  in  about  eight  weeks. 

THIRD    SUB-DIVISION. 

The  Third  subdivision  includes  six  chronic  cases,  with  no 
deaths.  In  all  of  these  cases  there  had  been  histories  of  repeated 
attacks  of  pain  in  the  caecal  region  They  were  all  operated  dur- 
ing the  quiescent  stage      The  following  cases  are  wortl^-of  mention. 

Case  X- — O-  C  L,-  Always  been  healthy  ;  was  first  taken 
sick  about  the  middle  of  December  1891.  Had  fever  and  pain  over 
the  caecum  Was  sick  seven  weeks,  most  of  the  time  in  bed.  Was 
commencing  to  get  around  when  he  had  a  relapse  and  from  that 
time  on  he  had  frequent  attacks  of  pain,  lasting  several  days.  Be- 
tween these  acute  attacks  there  has  always  remained  some  tender- 
ness on  pressure,  over  the  caecum.  Patient  walks  drawn  over  to 
the  right  side  Examination  under  an  anaesthetic  revealed  a  dull- 
ness and  resistance  in  the  caecal  region. 

Operation — Incision  through  right  linea  semi-lunaris  The 
caecum  was  in  a  mass  of  adhesions  with  small  sinuses  dissecting  up- 
ward toward  the  liver  ;  the  appendix  could  not  be  found.  In  the 
lower  part  of  the  abscess  cavity  was  an  intestinal  concretion  about 
the  size  of  a  hazel-nut.  The  wound  was  packed  with  iodoform- 
gauze  and  the  ends  of  the  incision  brought  together  with  silk 
sutures  Dressings  were  made  every  day,  and  the  wound  washed 
out  with  boracic  acid  'solution.  During  the  first  two  week  there 
was  an  abundant  discharge  of  pus.  Patient  sat  up  during  the  third 
week,  and  left  Hospital  June  6th  During  the  summer  gained  con- 
siderably in  flesh,  but  the  sinus  continued  to  discharge,  and  occa- 
sionally a  few  seeds  worked  their  way  out-  In  November  had  an 
attack  of  pleurisy,  and  made  a  slow  recovery.  Patient  has  since 
returned  for  a  second  operation,  in  which  the  appendix  was  found 
and  removed,   and  the    hole  in  the  intestine  sewed   with  cat-gut. 


14 

The  patient  is  still  in  the  Hospital  ;  being  up  and  about,  the  wound 
being  closed  with  exception  of  few  points  of  granulation. 

Case  XII  — C.  S.  Always  had  good  health.  In  August, 
1892,  had  an  attack  of  appendicitis.  Was  in  bed  two  weeks.  Since 
then  has  had  some  tenderness  remaining  over  the  caecum,  and  on 
the  slightest  exertion  the  pain  returned  so  that  he  has  not  been 
able  to  attend  to  any  duties.  At  the  operation,  numerous  small 
abscesses  were  found  around  the  caecum,  which  was  in  a  mass  of 
adhesions.  The  patient  was  too  weak  to  stand  a  prolonged  opera- 
tion, and  the  appendix  was  not  found.  The  wound  was  tamponed 
with  iodoform  gauze,  and  patient  improved  rapidly  after  the  oper- 
ation, leaving  the  Hospital  October  29th.  During  the  winter, 
patient  has  been  able  to  attend  to  his  duties  as  a  barber,  and  his 
general  condition  is  much  improved.  The  sinus  closes  from  time 
to  time,  and  again  breaks  open,  with  a  discharge  of  pus.  Patient 
has  since  undergone  a  second  operation  in  which  the  appendix  was 
found  and  removed.     Wound  has  now  entirely  closed. 

Case  XIV. — A.  S.  Had  his  first  attack  of  appendicitis  in 
February,  1890.  Was  confined  to  the  house  about  two  months.  In 
June,  1890,  noticed  an  enlargement  in  the  caecal  region,  which 
steadily  increased  in  size,  and  was  opened  and  drained  by  Dr. 
Allen  in  August,  1890.  Several  concretions  were  removed,  but  the 
appendix  was  not  found.  No  exhaustive  search  was  made,  however, 
since  it  was  hoped  the  removal  of  the  concretion  would  end  the 
trouble.  A  slight  discharge  of  pus  continued  until  May  1891,  when 
the  sinus  closed.  Since  then  there  has  been  a  discharge  of  pus 
about  every  two  or  three  months.  A  second  operation  was  per- 
formed in  January,  1893.  The  stump  of  the  appendix  was  found, 
with  a  concretion  in  the  open  end.  Appendix  was  removed  and 
opening  in  caecum  closed  with  cat-gut  sutures.  Patient  made  an 
uninterrupted  recovery.  L,eft  Hospital  February  14th,  and  a  week 
later  wound  was  entirely  healed . 

Case  XV.— T.  S.  T.     Always  been  healthy.     During  the  last 


15 

10  or  12  years  has  had  attacks  of  pain  in  the  caecal  region  about 
every  six  months,  and  of  late  years  the  attacks  seem  to  be  growing 
more  frequent.  Pain  had  always  been  localized,  and  was  accom- 
panied by  slight  rise  in  temperature,  the  patient  being  confined  to 
her  bed  about  a  week.  In  November,  1892,  had  her  last  attack,  and 
was  treated  by  Dr.  E.  F.  Gushing.  There  was  no  dullness,  no  in- 
duration, but  the  symptoms  pointed  to  appendicitis,  and  an  opera- 
tion was  advised  At  the  operation,  no  signs  of  peritoneal  inflam- 
mation were  present  around  the  caecum.  The  appendix  hung  free 
in  the  abdominal  cavity.  There  was,  however,  slight  constriction 
at  the  base,  and  two  small  concretions  could  be  felt  in  its  interior. 
The  appendix  was  removed,  and  opening  in  the  caecum  sewed  with 
cat-gut  Abdominal  incision  was  closed  with  silkworm-gut 
sutures,  do  drainage  being  used.  The  wound  healed  by  first  inten- 
tion and  patient  made  an  uninterrupted  recovery. 


Remarks. 

Given  in 
detail  below. 

No  autopsy 
could  be 
obtained. 

Sinus  entirely 

closed  in 

October  and 

no  trouble 

since. 

X 

9; 

C3 

P? 

a,       —      c- 

q    .3    -a 

■A 

Irrigation 

and 
Drainage. 

Irrigation ; 

No 
drainage. 

Irrigation ; 

Glass 

drainage 

tube. 

Irrigation ; 

No 
drainage. 

cS 

99 

H 

99 

< 

Excessive    tympan- 
nites  during  recov- 
ery. 

Went     home    June 
13th,    feeling   very 
well. 

Patient    very  weak 
after    operation; 
well    stimulated : 
symptoms  of  peri- 
tonitis   came    on 
during  second  day. 
Could    obtain     no 
movement  of  bow- 
els;  patient  grad- 
ually failed. 

Patient  made  an  un- 
interrupted  recov- 
ery and  left  Hospi- 
tal June  28th.     In 
July  an    abscess 
opened     at     lower 
end  of  incision  and 
discharged       until 
September,     when 
silk   ligature    from 
pedicle  came  away. 

3 
u 
CD 

6  quarts  clear  ascitic 
fluid.      Right    ovary 
size  of  two  fists.    Ad- 
herent' and  cysts  rup- 
tured during  remov- 
al.     Intestines    and 
peritoneum     thickly 
studded    with   small 
growths  size  of  millet 
seeds. 

Removed  multilocu- 
lar  suppurating  cyst 
of  left  ovary,  with 
firm  adhesions  to 
omentum,  abdominal 
wall,  sigmo  id  flexure 
and  pelvic  wall. 

Right  ovary  also  cys- 
tic degenerated,  and 
was  removed. 

Meekel'sdiverticulum 
extended  from  ileum 
to  junction  of  right 
tube  with  uterus,  lig- 
ated  and  cut  through 
diverticulum. 

Removed  multilocu- 
lar  cyst  of  right  ovary 
containing  two  q'ts 
of  a  chocolate  color- 
ed fluid. 

Left  ovary  cystic  and 
was  removed. 

o 

Percussion  varied  at 
different     examin- 
tions.    At  one  time 
precussing    for  as- 
cites,   at    another 
for  tumor. 

F 1  u  c  tu  a  t  i  o  n 
distinct;    tiirm   re- 
sistance in  pelvis. 

Physical  signs  ovar- 
ian  tumor,    reach- 
ing  nearly   to   um- 
bilicus;    not    very 
movable;     fluctua- 
tion distinct. 

3!  x 

os  a 

&  o 

•oS   . 
a  a  n. 
i9  g  a 

*    % 

~  c  a 

09 

Pn 

c 

X 

£ 

Always  healthy;  men- 
struated at  18;  meno- 
pause at  48;   married 
at  27;  had  6  children 
—lst  child  at  28,  last 
child  at   41.      Never 
had  any  trouble  until 
March,     1892,     when 
noticed    that    abdo- 
men was  enlarged. 

Previous  good  health; 
menstruated  at  14 — 
regular;  married  at 
22— never  pregnant; 
5  months  ago  noticed 
abdomen  was  larger, 
and  has  lost  flesh. 

During  last  six  weeks 
has  had  severe  pain 
on  left  side. 

Good    health;    men- 
struated at  14:  never 
regular:    married  at 
20;   pregnant  for  lst 
time  at  27;    miscar- 
ried   at  6th    month. 
Had  living  child  at 
28;   easy  labor;  good 
recovery.    In  Spring 
'91,     noticed     heavy 
feeling  in  pelvis,  and 
could  feel  a  growth 
in  median  line.    Has 
steadily  increased  in 
size.     Menstruates 
regularly. 

Date  and 
Place  of 

Operation. 

May  17, 

1892. 

Charity 
Hospital. 

May  28, 
1892. 

Charity 
Hospital. 

May  30, 
1892. 

Charity 
Hospital. 

Ph      on 

Dr.  B. 
Krause. 

»        X 

iz;     a 
&     4 

Dr.  L.  G. 

Moore 

of 

Kinsman. 

Nat. 
Age, 
Social 
Condi- 
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Patient 
writes  she  is 
doing  well. 

Steadily 
gaining 
strength. 

« 

rt 

K 

Irrigation. 

No 
drainage. 

No 
Irrigation. 

No 
drainage. 

Irrigation. 

No 
drainage. 

Uninterrupted     re- 
covery. 

Sat  up  in  3d  week. 

Went  home  March 
9th. 

March    Uth   devel- 
oped slight  phlebi- 
ties  of  left  leg. 

Left  Hospital,  April 
5th. 

Uninterrupted      re- 
covery. . 

Left  Hospital,  Apr. 

24. 

Removed  cyst  of  right 
ovary,  weighing  six- 
teen lbs.  Consisted 
of  large  cyst  and 
deep  in  pelvis  was  a 
more  solid  portion 
containing  papillary 
cysts. 

Adherent  to  omentum 
and  auterior  abdom- 
inal wall.  Left  ovary 
atrophic,  not  remov- 
ed. 

Removed  simple  cyst 
of  right  ovary,  weigh- 
ing b]4  lbs.  Contents 
of  very  thick,  choco- 
late colored  fluid. 
Long  pedicle:  no  ad- 
hesions. 

Left    ovary    normal ; 
not  removed. 

Removed    cystic  de- 
generated    ovary 
right  side— size  of  an 
egg.     Left  tube    en- 
larged and  contained 
pus.    Was  in  a  mass 
of    adhesions,      and 
was    removed    with 
left  ovary- 

Right  chest  full  of 
fluid. 

Tumor   extended    2 
inches -above   um- 
bilicus. 

Tumor    very    mov- 
able and  reaching 
above    umbilicus — 
Very  tense:    indis- 
tinct fluctuation. 

t->'2'5 

*     a 
>.-© 

CD  K  a 

Always  healthy;  men- 
struated at  15:  meno- 
pause at  57:    1  child 
at   26;       no    miscar- 
riages: had  pleuritic 
effusion:      aspirated 
3  times. 

Cyst  aspirated  twice. 

History  given  in  de- 
tail below. 

Healthy;  menstru- 
ated at  16  —  regular ; 
first  child  at  27;  2nd 
at  29,  no  trouble. 

Three  y'rs  ago  noticed 
tumor  on  right 
side,  grew  slowly  at 
first,  but  rapidly  dur- 
ing last  six  months. 
Monthlies  regular- 
no  pain. 

Always  been  delicate; 
menstruated    at    16 ; 
married  at  25;  never 
pregnant.     During 
last  two    years   had 
pain  in  back  and  pel- 
vis.  During  last  year 
not  able  to   do  any 
work :  had  an  escape 
of  pus  several  times 
from  vagina;  periods 
regular. 

Feb.  16, 
1893. 

Cliarity 
Hospital. 

March  1, 
1893. 

Lakeside 
Hospital. 

March  20, 
1893. 

Charity 
Hospital. 

Dr.  G.  R. 

Sherwood 

of 

Elyria. 

Dr.  A. 
Brintuall 

of 
Liverpool. 

-<                "^                p: 

r-'                            P3 

< 

|_l                       « 

x 

*      5 

20 


'  The  above  tables  contain  12  cases  with  two  deaths  ;  the  cause 
of  death  in  both  cases  being  peritonitis.  The  usual  antiseptic  pre- 
cautions were  observed  during  the  operations.  The  abdominal 
cavity  was  irrigated  in  all  cases  in  which  there  was  much  hemorrh- 
age or  escape  of  the  contents  of  the  cysts.  Drainage  was  em- 
ployed only  in  cases  where  oozing  of  blood  continued  after  the  liga- 
tion of  adhesions.  In  those  cases  in  which  drainage  was  used,  the 
tube  was  cleared  by  a  syringe  repeatedly  during  the  first  24  hours 
and  was  revolved  at  each  dressing.  As  soon  as  the  oozing  ceased, 
the  drainage  tube  was  removed  and  a  small  piece  of  gauze  was 
placed  in  the  external  opening.  Silk  worm  gut  was  used  for  sutures, 
taking  care  to  include  all  the  layers  of  the  abdominal  wall,  the 
sutures  being  removed  usually  about  the  tenth  day.  The  wounds 
as  a  rule  healed  by  first  intention,  with  now  and  then  an  occasional 
stitch  abscess.  The  bowels,  excepting  when  tympanites  developed 
earlier,  were  moved  on  the  fourth  day  by  small  and  repeated  doses 
of  calomel  and  salts.  The  patients,  in  order  to  avoid  the  dangers 
of  hernia,  were  not  allowed  to  sit  up  until  the  third  week.  The 
following  cases  are  given  somewhat  in  detail. 

Case  I. — M.  M.  Had  always  been  healthy.  In  March,  1892, 
noticed  that  abdomen  was  enlarged,  and  called  Dr.  Kraus..  Was 
seen  in  consultation,  with  Dr.  Allen,  in  March,  and  again  in  April. 
The  physical  signs  varied  at  the  different  examinations  ;  at  one  time 
percussing  for  ascites,  and  at  another  for  tumor.  Ascites  was  diag- 
nosticated and  an  exploratory  laparotomy  was  advised  and  per- 
formed May  17th.  The  abdominal  cavity  contained  about  six  quarts 
of  clear  fluid.  The  right  ovary  was  cystic  degenerated,  containing 
several  cysts  as  large  as  eggs.  The  cysts  easily  ruptured  during 
removal.  Microscopic  examination  showed  the  tumor  to  be  a  Papil- 
lary Cystoma.  The  intestines  and  peritoneum  were  thickly  studded 
with  small  growths.  The  patient  made  an  uninterrupted  recovery, 
and  left  the  Hospital  June  13th.  The  ascites,  however,  returned 
in  the  latter  part  of  August.     During  the  fall  the   patient  was  twice 


21 

aspirated  and  several  quarts  of  fluid  drawn  away.  Health  gradually 
failed  and  patient  died  March  1893.  No  post  mortem  could  be  ob- 
tained; It  is  presumable  that  the  small  tumors  on  the  peritoneum 
and  intestines  were  small  papillae  which  had  escaped  by  rupture  ot 
a  cyst  and  had  attached  themselves  throughout  the  peritoneal 
cavity. 

Case  IV. — A.  E.  D.  In  the  fall  of  1889,  noticed  a  small  lump 
in  the  left  side  which  gradually  increased  in  size  and  caused  pain. 
In  May,  1891,  laparotomy  was  performed  by  a  surgeon  in  Nashville, 
Tenn.  The  tumor  was  adherent  and  could  not  be  removed.  The 
cyst  was  opened  and  stitched  to  the  abdominal  wall,  with  drainage. 
Patient  was  entirely  healed  in  about  three  months,  but  pains  con- 
tinued, about  the  same  as  before  operation.  In  August,  1891,  tumor 
again  commenced  growing  and  pain  became  more  severe,  so  that 
patient  was  confined  to  the  house  most  of  the  time.  A  physical 
examination  revealed  a  hard  mass  on  the  left  side  of  the  uterus,  but 
owing  to  the  cicatrix  and  adhesions  from  former  operations  nothing 
could  be  distinctly  felt.  Operation  was  advised  and  performed 
June  1  st.  The  old  cicatrix  was  dissected  out;  right  ovary  cystic 
degenerated  and  removed.  L,eft  ovary  was  in  a  mass  of  adhesions 
and  removed  with  much  difficulty.  Considerable  oozing  continued 
after  irrigation  and  wound  was  tamponed  with  iodoform  gauze. 
The  operation  was  much  prolonged,  and  patient  left  table  in  a  very 
weak  condition.  Was  freely  stimulated,  and  reacted  well.  Patient 
made  a  good  recovery  and  left  the  Hospital  July  18th.  Wound 
entirely  closed,  with  the  exception  of  a  few  granulating  points. 
Patient  was  of  a  very  melancholy  disposition,  and  after  leaving  the 
hospital,  became  much  worse.  During  the  fall  and  winter,  had 
several  attacks  in  which  she  was  violent,  but  at  other  times  was 
perfectly  rational. 

Case  VII. — O.  W.  Interligamentous  Cyst.  Was  very  adher- 
ent, and  small  piece  of  the  sack  was  left  behind.  Glass  drainage 
tube  was  carried  down  to  this  point.     The  patient  reacted  well  after 


22 

operation  and  had  a  good  pulse.  There  was  considerable  oozing  of 
blood.  Tube  was  cleared  every  two  hours  and  rotated  at  each  dress- 
ing. Patient  went  along  nicely  for  four  days.  Pulse  about  ioo  and 
temperature  under  ioo.  The  third  day  gave  calomel  and  salts,  and 
obtained  a  good  movement  of  the  bowels.  Upon  fourth  day  drain- 
age tube  was  removed,  and  in  spite  of  the  great  care  that  had  been 
taken  at  each  of  the  dressings,  a  piece  of  the  omentum  had  grown 
through  one  of  the  holes  in  the  tube.  This  was  cut  away,  but  in 
so  doing,  adhesions  were  broken,  opening  channels  of  infection  into 
the  general  peritoneal  cavity.  That  evening  temperature  went  to 
10 1  ;  pulse  to  1 20.  Complained  of  intense  abdominal  pain.  The 
following  morning  inserted  finger  deep  into  the  wound  and  syringed 
out  a  purulent  material.  Tympanites  rapidly  developed  and  abdom- 
inal pain  became  more  severe.  Patient  gradually  failed  and  died 
on  the  fifth  day  after  operation.     No  autopsy  could  be  obtained. 

Case  X. — A.  D.  T.  Was  perfectly  well  until  May,  1891,  when 
she  had  influenza,  but  not  severe  enough  to  call  a  physician.  Did 
not  fully  recover,  and  was  left  with  a  cough.  Lost  considerable 
flesh.  In  September,  1 891,  called  a  physician  to  treat  the  cough. 
Had  no  pain  in  side.  About  April,  1892,  noticed  that  the  abdomen 
was  enlarged.  Had  previously  had  a  fullness  in  the  left  side,  low 
down  in  the  plevis.  Dr.  Allen  saw  the  patient  in  consultation  with 
Dr.  Sherwood  in  July,  1892.  Diagnosticated  ovarian  cyst.  Patient 
also  had  at  that  time  an  effusion  in  the  right  plural  cavity.  Was 
aspirated  on  July  26th  and  removed  three  quarts  of  serum.  Advised 
her  to  return  home  and  wait  until  fall  before  considering  operation. 
November  1st,  1892,  patient  again  returned.  Was  again  aspirated 
with  removal  of  three  quarts  of  fluid.  Refused  to  operate  the  tumor 
until  the  general  symptoms  should  improve.  December  22nd,  1892, 
abdomen  was  enormously  distended.  Dr.  Sherwood  aspirated  the 
tumor,  removing  12  quarts  of  fluid.  January  25th  the  abdomen 
was  again  filled  and  aspirated,  removing  nine  quarts  of  fluid.  These 
aspirations  were  advised  since  the  pressure  of  the  fluid  was  telling 


23 

seriously  on  patient.  Patient  now  begged  to  be  operated  at  any 
risk,  so  it  was  decided  that  the  chest  should  again  be  aspirated,  and 
the  patient  brought  for  operation  in  a  few  days  afterwards.  Febru- 
ary 7th,  1893,  Dr.  Sherwood  drew  off  three  quarts  serum  from  the 
right  chest.  The*  patient  entered  Charity  Hospital  February  14th. 
Operated  February  16th.  Dr.  J.  H.  Lee  administered  the  chloro- 
form. Removed  tumor  of  right  ovary  weighing  16  lbs.  Was  ad- 
herent to  the  omentum  and  abdominal  wall.  Abdomen  was  closed 
with  silk  worm  gut  sutures.  Patient  came  out  of  operation  with  a 
pulse  of  76.  Reacted  nicely.  No  vomiting;  bowels  moved  without 
cathartic  on  second  day.  Stitches  removed  on  seventh  day.  Wound 
absolutely  healed.  Patient  sat  up  the  third  week  and  went  home 
March  9th.  Has  been  no  return  of  effusion  in  the  right  side,  and 
patient  is  perfectly  well.     < 


09 

U 

oS 

£ 

93 

Patient     left 
hospital  May 
31st.  Has  had 
no  return   of 
trouble  and  is 
entirely  well. 

Volvulus  of 
ileum    with 
complete   ob- 
struction. 

Patient     left 
hospital  July 
31st.     Health 
much  improv- 
ed and  feeling 
better      than 
for  several 
years. 

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Postmortem 
showed  peri- 
tonitis as  cause 

of  death. 

Ligatures  were 

in  place. 

1 

as 

8 
O 

as. 

3  *■ 

a-  c 
£p 

Has    at    times 
some  pain  but 
is  steadily  im- 
proving and  is 
able  to  attend 
to    household 
duties. 

Went  home  in 
about  4  weeks 
a  f  t  e  r   opera- 
iion.  Perfectly 
well. 

Death 
on  3d 
day. 

« 

■A 

Irrigation ; 

No 
drainage. 

© 

M 

Glass 

drainage 

tube. 

a 
_© 

.2 

u 

No 
drainage. 

Patient  did  well  for 
24  hours, then  pulse 
and     temperature 
commenced    going 
up.  Tympauiles  de- 
veloped    and     no 
movement  could  be 
obtained;    symp- 
tons  of  peritonitis 
rapidly  developed. 

-a 

o 
% 
fit 

5-5. 

Uninterrupted      re- 
covery; had  no  bad 
symptoms    of   any 
kind. 

Ovaries  much  enlarg- 
ed and  hardened. 
Tubes  also  thickened 
and  adherent ;  uterus 
somewhat  enlarged 
and  contained  sev- 
eral small  fibroids. 

Tubes  and  ovaries 
were  removed. 

ii 

5 
S  •- 

XTS 
-  13 

*H 

>  3 
O  3y 

=X3 

■s. 

-x 

f- 

- 

> 

■— 
> 

enlarged     and    in    a 
mass    of   adhesions. 
Ovaries  and  tubes  re- 
moved    with    great 
difficulty;  considera- 
ble hemorrhage,  nec- 
essitating   drainage. 

a3 

© 

CD 
N 

'53 

"3 
2 

t3-t= 
IS 
'-  r. 

Z  a 
—  a 

smaller  and  contain- 
ed pus;  ovaries  much 
enlarged  and   cystic 
degenerated;     many 
loose  adhesions;  re- 
moved    tubes      and 
ovaries. 

Enlargement  of 
tubes  and  ovaries. 

Extreme  tenderness 
on  slightest  pres- 
sure. 

Tubes  enlarged ;  left- 
ovary  much  enlarg- 
ed;   could  not    be 
moved,  very  tender 
on  pressure. 

Under  ether   could 
feel  greatly  enlarg- 
ed tubes  and  ovar- 
ies; uterus  normal 
size. 

Medium  health;  mar- 
ried at  30.  Never 
pregnant;  during 
past  few  years  had 
painful  menstruati'n 
and  also  continued 
pain  between  periods 

Can  not  attend  to  any 
duties  and  slightest 
exertion  brings  on 
severe  pelvic  pain. 

"3 

z 
s 

•--x  ~ 

CS—  CD 
X  -si 

S'S1  °^ 

CMC   ~ 

tS  a!  3 

< 

so 

s 

■5 

- 

1- 

eo 

23    had     full     term 
child ;  miscarried  a- 
gain  at  2<i  and  since 
then  has  never  been 
well— confined  to  bed 
a  good  share  of  time ; 
Periods^irregular  and 
accompanied  by  se- 
vererpain. 

Healthy  until  courses 
commenced  at  18 ;  al- 
ways had  great  pain ; 
married  at  20;  since 
then  has  more  severe 
pains;    during    past 
half  year  has  had  fre- 
quent    and    sudden 
discharges   of     pus; 
has  never  been  preg- 
nant. 

July  13, 

1892, 
Charity 
Hospital. 

CN 

"5 

1892. 
Charity 
Hospital. 

o 

CO 

> 

© 

1892, 
Charity 
Hospital. 

Dr.  F.  B. 
AVilliam- 

son, 
Massillon, 

Ohio. 

CO 

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Lanter- 

man, 

Bellevue, 

Ohio. 

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27 

The  above  tables  include  eight  cases  with  two  deaths,  one  death 
occurring  on  the  17th  day,  from  intestinal  obstruction  ;  the  other 
due  to  peritonitis.  The  details  of  operation  were  about  the  same  as 
those  carried  out  in  the  ovariotomy  cases. 

^Case  I. — C.  A.  S.  Had  a  discharge  of  bad  smelling  pus  for 
about  10  months  before  operation.  Case  was  seen  in  consultation 
with  Dr.  H.  K.  Cushing.  Symptoms  pointed  to  either  a  salpingitis 
or  a  cancer  of  the  body  of  the  uterus.  Laparotomy  was  performed 
April  1  st.  The  tubes  were  somewhat  inflamed,  and  were  removed 
with  the  ovaries.  Abdominal  incision  healed  by  first  intention. 
The  discharge  ceased  for  a  few  days  after  operation  and  again  be- 
came profuse  and  very  offensive.  The  interior  of  the  uterus  was 
washed  out  daily  and  treated  with  applications  of  iodine,  but  discharge 
still  continued.  May  12th  dilated  and  curetted  uterus,  packing 
uterine  cavity  with  iodoform  gauze.  May  14th  gauze  was  removed 
and  uterus  was  daily  washed  with  bichloride  solution,  and  interior 
treated  with  tincture  of  iodine.  Patient  rapidly  improved.  Dis- 
charge diminished  and  finally  ceased.  Left  hospital  May  31st.  Has 
since  had  no  treatment,  with  no  return  of  the  discharge.  Patient 
writes  that  she  is  feeling  very  well,  and  able  to  attend  to  her  house- 
hold duties. 

Case  II. — M.  S.  At  the  operation  the  enlarged  tubes  con- 
taining pus  were  removed  with  the  ovaries.  Patient  reacted  well 
after  the  operation.  On  third  day  calomel  and  salts  were  given, 
causing  two  good  movements.  Patient  did  nicely  until  the  ninth 
day,  temperature  ranging  about  99 ;  pulse  90.  Abdominal  stitches 
were  removed  on  the  seventh  day ;  wound  entirely  healed  with  ex- 
ception of  two  small  points  of  superficial  suppuration.  On  9th  day 
patient  was  taken  with  sudden  pain  in  the  abdomen  just  after  having 
a  movement  of  the  bowels,  and  on  the  following  day  commenced  vom- 
iting a  stercoraceous  material.  Stopped  all  nourishment  by  stom- 
ach, and  gave  enemata  of  beef  juice  and  stimulants.  Salts  were 
given    in    repeated   doses  but   no    movement   could    be    obtained. 


28 

Patient  gradually  failed  and  died  on  the  17th  day.  Post  mortem  on 
the  following  day.  The  superfical  part  of  the  abdominal  incision 
had  opened,  evidently  as  a  result  of  the  low  condition  preceeding 
death.  The  peritoneum  was  closed  and  the  cavity  was  free  from 
infection.  Small  intestine  was  distended  down  to  19  inches  above 
the  caecum.  Here  the  intestine  had  formed  adhesions  to  the  pedicle 
and  was  twisted  upon  itself  completely  occluding  the  caliber  of  the 
gut.      There  was  no  peritonitis  or  free  fluid  in  the  abdominal  cavity. 

Case  V. — C.  M.  H.  Tubes  and  ovaries  were  in  a  mass  of 
adhesions  and  were  removed  with  great  difficulty.  Considerable 
hemorrhage  followed,  requiring  abdominal  drainage.  Patient  reacted 
well,  but  suffered  intense  pain.  The  day  after  operation  patient 
developed  excessive  tympanites.  Small  and  repeated  doses  of  calo- 
mel were  given,  followed  by  Rochelle  salts,  but  no  movement  was 
obtained  and  patient  commenced  vomiting.  In  the  evening  patient 
took  a  very  serious  turn  for  the  worse.  Vomited  incessantly  and 
was  in  great  pain ;  pulse  about  140,  temperature  99^.  Commenced 
giving  rectal  injections  of  aloes  and  oil.  Injections  came  away  with 
some  lumps  of  faecal  material,  but  tympanites  continued.  On 
second  day  commenced  giving  drachm  doses  of  Rochelle  salts, 
followed  by  rectal  injections ;  passage  of  small  amount  of  faecal 
material.  The  third  day  patient  was  slightly  better,  but  could  retain 
nothing  on  the  stomach.  On  fourth  day  gave  rectal  injections 
containing  two  ounces  of  Rochelle  salts,  but  could  get  no  satisfac- 
tory movement.  On  fifth  day  patient's  condition  was  very  serious; 
excessive  tympanites  and  extreme  tenderness  over  entire  abdomen. 
Hot  fomentations  were  applied  and  injections  of  salts  and  water 
again  given  without  bringing  away  any  faecal  material.  Patient's 
condition  was  almost  hopeless;  pulse  about  140,  temperature  102. 
Drainage  tube  had  been  previously  removed  and  gauze  drainage 
.substituted.  On  sixth  day  again  gave  injections  of  aloes  and  oil  and 
at  same  time  drachm  doses  of  Rochelle  by  stomach,  resulting  in 
two    good  movements  of  the  bowels  and  passage  of  much  flatus. 


29 

This  was  the  first  satisfactory  movement  of  the  bowels  after  the 
operation.  Patient  from  this  time  on  steadily  improved,  but  had 
continued  pain  in  pelvis,  aggravated  by  each  movement  of  the 
bowels.  The  abdominal  wound  healed  by  granulation.  The  patient 
went  home  December  7th.  For  some  weeks  after  the  operation 
severe  pain  came  on  with  each  movement  of  the  bowels,  but  this 
gradually  subsided,  and  patient  is  now  entirely  well. 


Remarks. 

Healed  in 
seven  weeks 

after 

operation, 

No   trouble 

since. 

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The  above  table  includes  five  eases  of  operations  for  uterine 
fibroids ;  in  three  cases  abdominal  hysterectomy  was  performed  and 
the  stump  treated  extra-peritoneally.  In  one  case  the  fibroid  was 
enucleated  without  removal  of  the  uterus.  In  the  other  case  both 
ovaries  and  an  intramural  fiibroid  were  removed. 

CaseI. — L,.B.  When  about  twenty-two  years  of  age  began  hav- 
ing severe  pain  at  monthly  periods.  In  February,  1890,  noticed  a 
tumor  low  down  in  the  median  line,  which  steadily  increased  in  size. 
Patient  consulted  Dr.  Allen  in  June,  1892.  Periods  lasted  five  or 
six  days  and  were  attended  with  such  severe  pain  that  patient 
administered  chloroform  to  herself.  A  large  amount  of  blood  was 
lost  at  each  period  and  the  general  condition  of  the  patient  was 
extremely  poor.  Advised  postponement  of  operation  until  fall  and 
sent  patient  up  the  lakes.  During  the  summer  gained  seven  pounds 
and  in  September  returned.  Dr.  H.  J.  Lee  gave  the  anaesthetic, 
ether.  The  uterus  extended  two-thirds  the  distance  to  umbilicus  ; 
there  were  no  adhesions.  Applied  elastic  ligature  around  uterus ; 
and  incised  and  removed  an  intramural  fibroid  before  amputating  the 
uterus  ;  the  mass  weighed  three  pounds.  Applied  serre-neud  to 
the  stump  and  sutured  extra-peritoneally ;  heavy  ligatures  of  silk 
were  applied  to  the  broad  ligaments.  Patient  reacted  well  from  the 
operation.  Had  suppression  of  urine  until  the  following  morning, 
when  a  normal  quantity  was  drawn  by  catheter.  The  serre-neud 
was  removed  on  the  eighteenth  day.  Wound  was  entirely  healed 
in  about  seven  weeks. 

Case  II. — A.  D.  First  noticed  enlargement  of  the  abdomen  in 
1888,  but  had  no  trouble  at  monthly  periods  until  spring  of  1892, 
then  commenced  losing  large  quantities  of  blood.  Periods  would 
last  three  weeks  with  usually  only  an  interval  of  one  week. 
Patient  did  not  suffer  much  pain,  but  could  not  work  on  account  of 
weakness  from  excessive  loss  of  blood.  Dr.  Allen  saw  patient 
first  in  June,  1892.  Advised  a  course  of  tonics,  and  a  postponement 
of  operation  until  fall.     Was  operated  September  28th,  1892.     Dr. 


33 

Lee  gave  anaesthetic — ether.  On  opening  the  abdominal  cavity, 
found  a  fibroid  in  the  omentum  about  the  size  of  a  duck's  egg,  which 
had  become  completely  detached  from  the  uterus,  and  was  receiving 
its  blood  supply  from  the  omentum.  Removed  fibroid  and  piece  of 
omentum.  Right  ovary  was  adherent  to  the  omentum  and  intestine; 
left  ovary  adherent  to  the  pelvic  wall.  Both  ovaries  and  tubes 
removed.  In  anterior  uterine  wall  was  a  fibroid  about  the  size  of  an 
orange ;  this  was  enucleated.  There  were  also  numerous  smaller 
intramural  fibroids.  The  uterus  could  not  be  removed  owing  to 
dense  adhesions  posteriorly  to  the  rectum  and  pelvic  wall,  so 
that  it  could  not  be  raised  out  of  the  pelvis.  Sewed  up  the  incision 
in  the  uterus  with  heavy  cat-gut. 

Abdominal  cavity  was  irrigated  and  incision  was  about  to  be 
closed,  when  suddenly  a  considerable  venous  hemorrhage  occurred 
from  the  adhesions  at  the  left  side  of  the  uterus.  The  whole  surface 
oozed  and  could  not  be  controlled  by  ligatures.  A  Mikulicz  tampon 
was  carried  down  into  this  cavity  to  control  the  hemorrhage.  On 
account  of  this  hemorrhage,  the  operation  was  much  prolonged  and 
the  patient  left  the  table  with  a  weak  pulse  of  about  140.  Previous 
to  the  hemorrhage  it  had  not  exceeded  90.  Stimulants  were  freely 
given  but  patient  did  not  react.  Dressings  were  changed  on  the  day 
after  the  operation,  but  tampon  was  not  disturbed.  The  hemorrhage 
ceased,  but  patient  did  not  rally  and  died  on  the  second  day  after 
operation.  Post  mortem  examination  showed  that  the  hemorrhage 
had  been  controlled  by  the  tampon  ;  no  clots  of  blood  were  found  in 
the  abdominal  cavity,  and  everything  in  the  way  of  sutures  and 
ligatures  was  in  place.  Death  resulted  from  loss  of  blood,  and 
patient  being  short  and  fat,  had  the  weak  heart  not  uncommon  in 
such  persons. 

Case  III. —A.  M.  Was  perfectly  healthy  until  the  fall  of  1886, 
when  she  noticed  the  abdomen  was  enlarged,  and  had  some  pains  at 
monthly  periods.  Tumor  steadily  increased  and  in  February,  1888, 
commenced  treatment  by  electricity.     Continued  to  grow  larger  and 


34 

in  October  1888,  the  fibroid  commenced  sloughing.  Patient  had  a 
high  fever  from  septic  absorption,  and  odor  from  the  discharge  was 
very  offensive.  In  November,  1888,  consulted  a  surgeon  of  this 
city,  and  during  the  winter  had  three  operations  in  which  pieces  of 
the  sloughing  fibroid  were  removed  with  the  ecraseur.  Patient 
showed  marked  signs  of  septic  absorption  after  each  operation. 
Was  treated  with  hypodermics  of  ergotine  between  the  operations. 
Left  the  hospital  in  April  considerably  improved  in  general  con- 
dition, but  discharge  soon  commenced  as  bad  as  ever.  In  Novem- 
ber, 1889,  had  the  fourth  operation  ;  October,  1890,  fifth  operation  ; 
September,  1891,  sixth  operation;  November,  1892,  seventh  opera- 
tion. At  each  time  a  piece  of  the  tumor  presenting  through  the 
cervix  was  removed,  but  the  discharge  would  reappear  in  a  few  weeks 
and  another  mass  would  present  itself  in  the  cervical  canal.  The 
odor  from  the  discharge  was  so  offensive  that  patient  suffered  the 
greatest  annoyance.  At  times  the  tumor  has  extended  down  in  the 
vagina  and  presented  at  the  vulva.  Dr.  Allen  first  saw  the  patient 
November,  1892,  but  refused  to  operate.  Patient  returned  repeatedly 
and  begged  to  be  operated  at  any  risk.  Has  never  lost  large 
amount  of  blood.  Patient  entered  Charity  Hospital,  December  5th, 
1892.  Was  thoroughly  cleansed  with  bi-chloride  douches  daily 
preparatory  to  operation  and  vagina  tamponed  with  iodoform  gauze. 
Uterus  was  very  movable ;  extended  to  umbilicus.  A  sloughing 
mass  about  the  size  of  an  orange  presented  at  the  cervix.  Operated 
December  10,  1892  Abdominal  incision  carried  two  inches  above 
umbilicus.  Broad  ligaments  were  first  ligated  with  silk,  and 
enucleation  performed  without  the  use  of  the  elastic  ligature.  The 
intestines  were  carefully  protected  with  sheets  of  iodoform  gauze ; 
the  uterus  was  incised  and  the  sloughing  mass  pulled  upward 
through  the  cervix.  A  serre-neud  was  then  applied  and  the  uterus 
amputated.  When  just  ready  to  flush  the  abdomen,  a  ligature  on 
the  right  broad  ligament  gave  way  and  severe  hemorrhage  occurred. 
Patient  up  to  this  time  had  had  an   excellent   pulse,   not  exceeding 


35 

85,  but  after  hemorrhage,  was  much  weakened  and  pulse  went  to 
125.  Patient  at  this  moment  came  out  partially  from  the  anaesthetic 
and  the  intestines  escaped  from  the  abdominal  cavity  and  were 
replaced  with  difficulty.  The  hemorrhage  was  controlled  ;  abdom- 
inal cavity  irrigated  and  a  glass  drainage  tube  carried  into  the 
pelvis.  Stump  was  sutured  extra-peritoneally  ;  incision  closed  with 
silk  sutures.  Patient  was  in  very  weak  condition  at  close  of  opera- 
tion. Was  freely  stimulated.  Drainage  tube  was  thoroughly 
cleansed  with  a  syringe  every  hour.  On  second  day  had  symptoms 
of  intestinal  obstruction.  Injections  of  aloes  and  oil  were  given 
with  no  effect.  On  third  day  symptoms  of  obstruction  increased, 
and  injections  were  repeated,  causing  a  good  movement.  Drainage 
tube  was  removed  on  the  third  day,  and  patient  went  on  to  an 
interrupted  recovery.  The  serre-neud  was  removed  on  the  20th 
day.  Patient  left  the  hospital,  January  31st,  and  was  entirely  healed 
about  the  middle  of  February. 


50 

it 

p3 

Patient  left 
Hospilal 
Aug.  4th. 

Has  fully 
recovered 
her  health. 

Sat  up 

March  12th. 

Entirely 

healed  in 

about  5  weeks 

after 

operation. 

No  trouble  of 

any  kind. 

50 

a3 

pi 

«' 

Irrigation 

and 
Drainage. 

Irrigation. 

Rubber 

drainage 

tubes 

and 

gauze 

tampon. 

Irrigation. 

Mikulicz 

tampon 

and 

gauze 

drainage. 

a 

CD 

H 
Oj 
-<< 

Tampon     and     one 
drainage   tube   re- 
moved on  3d  day; 
second  tube  remov- 
ed on  6th  day. 

On  21st  day  temper- 
ature went  up  and 
a  discharge  of  pus 
occurred. 

Tampon  rem  o  ved 
on  4th  day. 

Uninterrupted      re- 
covery. 

03 

Opened  Douglas'  cul- 
de-sac  and  removed 
clots  of  blood;  could 

'not  reach   ovarie s 
from    below:     made 
median      abdominal 
incision;     removed 
the    ruptured    tube 
and  ovaries. 

Opened   and  drained 
haematocele    of    left 
broad  ligament: 
right     ovary    cystic 
and   in    a    mass   of 
adhesions;    was 
opened     and      tam- 
poned. 

Both  tubes  removed. 

5 
y. 

Fluctua ti  ng    m  ass 
extended  to  umbil- 
icus. 

Cervix  was  soft  and 
os  uteri  open. 

Uterus  enlarged ;  ir- 
regular  mass   ex- 
tended on  left  side 
to  umbilicus:  fluc- 
tuation   at    upper 
portion.     On  right 
side   was    a   more 
dense  mass. 

Cervix  soft  and  os 
uteri  open. 

S3 

ft 

o 

s 

Healthy;    menstrua- 
ted at  11 ;  married  at 
21 ;   child  at  25— hard 
labor.     Patient 
thought  she  miscar- 
ried on  May  1st,  '92, 
and    had    continued 
discharge    of    blood 
until  operation. 

Sudden    pelvic    pain 
came  on  5  days  before 
operation,   and    a 
t  u  m  o  r    developed 
rapidly  in  abdomen. 

Healthy:    menstrua- 
ted at  13;  1st  child  at 
23;  2d  child  at  28. 

Flowed  continually  a 
slight  amount  of 
blood  from  Jan.  8th 
down     to     time    of 
operation. 

Ten  days  before  oper- 
ation   discovered 
tumor  in    abdomen: 
steadily  increased  in 
size;   severe  pain  of 
late  requiring  large 
hypodermics  of  mor- 
phine to  keep  pati- 
ent under  control. 

Date  and 

Place  of 

Operation. 

June  24th 
1892. 

Charity 
Hospital. 

Feb.  20th, 
1893. 

Residence 

of 
Patient. 

In  Con- 
sultation 
with 

a. 

ft    £ 

Dr.  C.  S. 

Ward 

of 

Warren, 

Ohio. 

Nat., 
Age, 
Social 
Condi- 
tion. 

Ger. 

28 
Mar. 

3>           ot           u2 

d 

M                                               ™ 

37 

Case  I — S.  B.  Always  healthy.  Menstruated  every  three 
weeks,  never  much  in  quantity.  First  confinement  at  25.  Had  a 
long  tedious  labor.  Was  badly  lacerated  but  made  a  good  recovery 
and  has  since  been  perfectly  well.  Was  unwell  for  the  last  time  in 
March,  1892.  In  April  had  no  courses  and  thought  she  was  preg- 
nant. About  April  27,  attempted  an  abortion  by  injecting  a  solution 
of  carbolic  acid  into  the  uterus.  On  May  1st  commenced  flowing 
and  had  considerable  pain  in  the  lower  part  of  the  abdomen.  Thick 
clots  were  discharged,  and  shreads  of  tissue,  which  the  patient  took 
to  be  membranes.  On  May  3rd  Dr.  J.  N.  Sipher  was  called. 
Bleeding  still  continued.  Patient  was  put  to  bed  and  antiseptic 
douches  given  twice  daily  for  five  weeks.  During  this  time  there 
had  been  a  slight  amount  of  blood  passed  each  day.  Patient  was 
then  allowed  to  get  up,  and  went  to  doctor's  office  for  treatment 
during  following  two  weeks.  On  June  19,  was  suddenly  taken 
with  severe  pains  in  the  pelvis  and  commenced  to  bleed  profusely. 
On  June  23,  at  5  p.  m.,  Dr.  Allen  was  first  called  in  consulation. 
Found  patient  in  great  pain,  and  satisfactory  examination  was  diffi- 
cult. Could  make  out  enlargement  in  lower  part  of  abdomen  with 
indistinct  fluctuation.  Advised  operation,  and  ordered  patient  to 
be  taken  to  the  hospital.  Operated  June  24th.  Patient  had  failed 
during  the  night;  pulse  was  about  130,  and  very  weak.  Under 
the  anaesthetic,  could  feel  a  mass  in  the  abdomem  extending  to  the 
umbilicus.  Fluctuation  was  distinct.  Haematocele  was  diagnosti- 
cated and  it  was  decided  to  open  and  drain  through  the  vagina.  On 
opening  Douglas'  sac,  about  two  quarts  of  clotted  blood  were 
removed.  It  soon  became  evident  that  this  method  would  not  suc- 
cessfully clear  the  abdomen,  consequently  the  abdomen  was  opened 
by  a  median  incision.  Both  ovaries  were  oedematous  and  enlarged 
three  or  four  times  normal  size,  and  were  shelled  out;  no  vessels 
needing  ligation.  Again  inserting  the  hand  a  mass  was  found  and 
and  removed.  This  proved  to  be  the  left«Fallopian  tube  which  had 
been  ruptured   by  the    ectopic  gestation.     Abdominal  cavity   was 


3« 

irrigated  and  two  rubber  drainage  tubes  introduced,  extending, 
through  abdominal  incision  and  out  through  the  vagina.  Mikulicz 
tampon  was  introduced  into  the  pelvis  and  ends  brought  out  through 
abdominal  opening.  Vagina  was  tamponed  from  below.  The  opera- 
tion was  made  as  quickly  as  possible,  owing  to  the  weak  and  failing 
condition  of  the  patient.  Pulse  after  operation,  160;  very  weak. 
Patient  was  freeely  stimulated,  but  did  not  react  fully  until  the 
following  morning.  Second  day  bowels  were  moved  with  calomel 
and  salts.  On  third  day  gauze  tampon  and  one  drainage  tube  were 
removed.  On  sixth  day  the  second  drainage  tube  was  removed  and 
gauze  drainage  introduced  through  abdominal  incision.  Patient 
went  along  nicely  until  July  15th,  when  temperature  went  to  102. 
On  July  16th  there  was  a  discharge  of  several  ounces  of  pus  through 
the  abdominal  incision.  Patient  rapidly  improved  and  left  the 
hospital  August  4th.  Wound  was  entirely  closed  about  eight 
weeks  after  operation,  and  patient  has  since  had  no  trouble  of  any 
kind.  She  still  continues  to  menstruate,  notwithstanding  both 
ovaries  were  entirely  removed 

Case  II — H.  S  Healthy  woman.  Menstruates  every  three 
and  one-half  weeks  ;  normal  quantity.  January  8th,  1893,  flow 
was  delayed  three  days  Had  considerable  pain  and  flowed  freely, 
a  slight  discharge  continuing  until  operation  on  February  20th. 
Temperature  had  ranged  from  99  to  101  ;  pulse  100  to  110.  About 
February  10th,  noticed  an  enlargement  of  the  abdomen,  which  has 
steadily  increased.  Dr.  Allen  was  called  to  Warren,  February  19th. 
Physical  examination  showed  the  os-uteri  to  be  patulous,  and  could 
insert  finger  one  and  one-half  inches.  An  oval  mass  extended 
upward  and  to  the  left,  to  the  level  of  the  umbilicus.  Fluctuation 
at  upper  portion  of  the  tumor.  Uterus  could  be  felt  enlarged 
three  times  normal  size  and  connected  with  this  mass.  On  the  right 
side  was  a  smaller  and  more  dense  tumor.  Operated  February  20th . 
Dr.  Ward  gave  the  anaesthetic — ether.  Median  incision ;  left 
broad  ligament  greatly  distended  with  blood.     Incised  and  removed 


39 

about  two  quarts  of  thick  clots.  Left  tube  was  tied  with  cat-gut, 
and  removed.  Right  ovary  cystic  degenerated,  and  in  a  mass  of 
adhesions.  Sac  of  the  haematocele  was  adherent  and  could  not  be 
removed ;  was  stitched  to  abdominal  wall  and  packed  with  iodoform 
gauze.  Mikulicz  tampon  was  carried  down  to  the  site  of  the  right 
ovary.  Closed  the  peritoneal  cavity  above  with  silkworm-gut 
sutures.  Patient  reacted  nicely  after  the  operation.  On  the  fourth 
day  the  tampon  was  removed.  Patient  went  on  to  an  interrupted 
recovery.     Was  entirely  healed  in  about  five  weeks. 


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4i 
The  above  table  inc'udes  three  cases  with  no  deaths. 
The  following  ease  is  especially  worthy  of  mention. 

Case  I — H.  T.     Was  entirely  well  until  early  spring  of  1890, 
then  commenced  having  pain  in  pelvis,   and  was  treated  for  retro- 
flexion.     In    February,   1892,  was   curetted,    the  operaiion   being 
followed  by  a  severe  attack  of  peritonitis.     Was  confined  to  bed 
several    weeks.     Has  since  steadily    lost  in  weight.     Had  almost 
constant    pain    in    abdomen,   accompanied    by   high    temperature 
every  evening.       Dr.  Allen    first   saw  patient,    October  7th,   1892. 
Abdomen  was  very  tender,  and  examination  difficult.      Could  make 
out  a  mass  extending  nearly  to  umbilicus.     Fluctuation  was  indis- 
tinct.    Laparotomy  was  performed  October  12th.     Median  incision  ; 
the  bladder  extended  to  within  two  inches  of  umbilicus.     Dissected 
to  the  side,  and  came  upon  several  small  cysts  containing  clear 
straw   colored   fluid.     Below   and  to    the   left,  opened  an  abscess 
cavity  containing  about  one  and  one-half  pints  of  thick  yellow  pus. 
In  this  cavity  was  found  a  lumbricoid  worm   eight  and  one-half 
inches  long.     Vagina  was  washed  with  bi-chloride,   and  a  counter 
opening    made   through  Douglas'  sac.     Introduced   two    drainage 
tubes  extending  through   abdominal  incision   and  into  the  vagina. 
Abscess  cavity  tamponed  witb   iodoform  gauze.     Patient    reacted 
well  from  the  operation,  and  in  the  evening,  temperature  came  down 
to  normal,   having  been  102  ^   on  the  two  evenings  preceding  the 
operation.     On  the  following  day  gauze  tampon  was  removed  and 
abscess  cavity  washed  out  daily.     November  6th,  one  of  the  drainage 
tubes  removed.       Patient  left  hospital,    November  19th.      Patient's 
condition  continued    improving  for   some  time.     In  latter  part   of 
January,   commenced  having    fever  at  night   and  abscess  did  not 
drain  well.     February  11th,   the  sinus  was  dilated  and  rubber  drain- 
age tubes  again  introduced.     Patient  has  since  had  less  fever,  but  is 
troubled    greatly    with    tympanites.       In    March,    a    faecal  fistula 
developed,  which  is  still  discharging. 


42 


MISCELLANEOUS   CASES. 


C.  H  — Pancreatic  Cyst. — American,  19  years  of  age,  single. 
Has  always  been  a  healthy  boy.  Nine  years  ago  while  running 
along  a  railroad  track,  stumbled  and  fell  on  the  end  of  a  stick, 
striking  in  the  region  of  the  stomach.  Since  that  time  patient 
thinks  there  has  been  some  slight  fullness  in  that  region.  In 
Deceml  >er,  1891,  commenced  having  pain  in  back  and  noticed  a 
tumor  in  region  of  stomach  ;  has  lost  flesh  rapidly  and  is  very 
anaemic.  Patient  was  seen  in  consultation  with  Dr.  O.  B.  Camp- 
bell. Entered  Lakeside  hospital  January  28th.  Physical  exami- 
nation showed  fullness  in  left  hypochondriac  region,  being  most 
prominent  about  four  inches  above  umbilicus  and  three  and  three- 
fourths  inches  to  left  of  median  line.  Lower  seven  ribs  on  left  side 
are  somewhat  bulging.  Dulness  extends  from  sixth  rib  in  the 
mammary  line  to  level  of  umbilicus.  Dullness  crosses  median  line 
three-fourths  of  an  inch  above  umbilicus,  extending  upward 
obliquely  to  the  right  and  is  lost  in  the  dullness  of  the  liver  in 
the  right  mammary  line.  Rest  of  the  abdomen  is  clear.  Area  of 
dullness  is  not  affected  by  change  of  position.  There  was  fluctua- 
tion over  the  prominent  portion  of  the  tumor.  Operation  February 
2nd  Incision  in  median  line  from  ensiform  cartilage  to  umbilicus  ; 
opened  peritoneal  cavhy.  Diver  in  normal  position  ;  stomach  to 
left  of  median  line,  extending  downward  and  to  the  right,  on  a 
line  from  the  seventh  rib  to  a  point  midway  between  umbilicus  and 
floating  ribs  of  right  side.  Stomach  was  empty.  Above  was  a 
thick  walled  cyst  between  stomach  and  left  lobe  of  liver.  Tumor 
was  incised  between  retaining  sutures,  and  circumference  of  open- 
ing stitched  with  silk  to  the  abdominal  walls.  Previous  to  this  a 
quart  of  fluid  had  been  removed  by  an  aspirator.  Fluid  was  thin  and 
of  a  greenish  brown  color  and  had  a  distinct  glistening  appearance. 
After  fluid  had  been  removed  there  remained  on  inner  surface  of 
cyst  shreads  of  brown  friable  tisssue.  Outer  surface  of  cyst  was 
slightly  redish  in  color,  and  uneven.     Cyst  wall  was  about  2  m.m 


43 


H.  C. — Pancreatic  Cyst — showing  prominence  over  region  of  tumor. 


45 


H.  C— Pancreatic  Cyst— showing  line  of  dullness. 


47 

in  thickness,  and  in  places  seemed  almost  cartilaginous.  Was  fairly 
firm,  and  did  not  tear  under  ligatures.  Cyst  was  irrigated  and 
cavity  packed  with  iodoform  gauze.  Patient  reacted  nicely  after 
operation.  The  tampon  was  removed  on  the  fifth  day.  The  walls 
of  the  cyst  gradually  collapsed,  portions  of  the  sack  coming  away 
in  shreads  Patient  left  the  hospital  March  13th.  A  small  sinus 
still  remains.     Fluid  removed  was  very  rich  in  cholesterin. 

F.  S. — Intestinal  obstruction  due  to  Volvulus. — Bohemian,  27, 
married.  A  strong  and  robust  fellow  ;  always  had  good  health. 
On  September  26th;  1892,  had  movement  of  bowels  at  3  a.  m.,  and 
was  immediately  taken  with  severe  abdominal  pain.  Dr.  A.  J. 
Cook  was  called  during  the  forenoon  ;  gave  salts  and  injections  of 
water,  but  could  obtain  no  movement.  Patient  suffered  consider- 
able abdominal  pain  throughout  the  day.  September  27th,  repeated 
salts  and  injections,  but  no  movement.  Patient  was  sent  to  Lake- 
side Hospital  in  the  evening.  Dr.  Allen  was  called  in  consultation 
September  28th.  Abdomen  was  greatly  distended,  and  patient  suf- 
fered intense  abdominal  pain.  Gave  small  and  repeated  doses  of 
calomel,  followed  by  salts  and  injections.  Patient  vomited  several 
times  during  the  day  and  no  movement  of  the  bowels  was  obtained 
September  29th  tympanites  increased.  Extreme  general  abdominal 
pain,  not  localized.  Temperature  100  1-5;  pulse  88.  Operation  at 
8  a.  m.  Dr.  Cook  present.  Median  incision.  First  examined  ap- 
pendix and  found  in  normal  condition.  On  opening  abdomen  a 
quantity  of  fluid  escaped,  presenting  intestine  deeply  congested. 
Commencing  at  the  caecum  the  ileum  which  was  greatly  distended, 
was  followed  upward,  and  suddenly  came  upon  collapsed  gut  about 
three  feet  from  the  ileo-caecal  valve.  The  collapsed  gut  was  followed 
along  for  about  three  feet  and  suddenly  came  upon  distended  gut, 
which  was  traced  to  the  stomach.  No  adhesions  were  found. 
Abdomen  was  irrigated,  and  incision  closed  with  silkworm  gut 
sutures.  Patient  was  in  considerable  collapse  at  close  of  operation  ; 
pulse  148,  weak  and  irregular.     Was  stimulated  freely.     At  2  p.  m. 


vomited.  Was  in  great  pain.  Gave  rectal  injection  of  oleum  ricini 
aloes  and  small  doses  of  calomel,  followed  by  dram  doses  of  Rochelle 
salts-  Bowels  moved  at  midnight,  and  again  at  3  a.  m.  the  follow- 
ing morning.  Next  day  patient  was  much  better.  Tympanites 
and  abdominal  pain  were  diminished.  October  5th  sutures  were 
removed.  Wound  suppurated  superficially,  and  healed  by  granu- 
lations. Patient  made  an  uninterrupted  recovery  ;  left  the  Hospital 
October  21st.      Has  since  been  perfectly  well. 

A.  M  H. — Laparotomy  for  Foreign  Body.  German,  aged  5 
years.  Patient  was  a  pale  looking  boy,  but  had  never  had  any 
serious  illness.  January  7th,  1893,  swallowed  a  toy  sleigh  bell. 
The  mother  of  the  boy  put  her  fingers  into  the  throat  to  remove  the 
bell,  but  only  pushed  it  further  down.  During  the  day  patient  had 
considerable  pain  in  the  throat  and  could  not  swallow  liquids,  all 
attempts  being  followed  by  immediate  expulsion  of  the  fluid  mixed 
with  blood.  Dr.  A.  Brintnall,  of  Liverpool,  saw  the  patient  in  the 
evening.  On  the  following  day  could  swallow  liquids  and  on  second 
day  took  soft  diet.  After  a  few  days  could  eat  vegetables  but  has 
never  been  able  to  swallow  meat.  Stools  have  been  closely 
watched  but  bell  has  not  come  away.  Has  had  considerable  cough, 
but  has  been  up  and  around  the  house  and  did  not  complain 
seriously  until  about  February  1st.  Was  then  taken  with  severe 
cramps  in  the  abdomen,  not  localized.  February  2nd  temperature 
was  101.  February  3rd,  102  in  the  axilla.  Passed  some  mucus  by 
bowel.  Dr.  Allen  was  called  to  Liverpool  February  4th.  The 
mucus  membrane  of  the  mouth  and  ncse  was  congested  and 
covered  with  ulcers.  Percussion  and  ascultation  of  the  chest 
revealed  nothing  abnormal.  Abdomen  somewhat  tympanitic  ;  no 
localized  dullness.  Complained  of  general  abdominal  pain.  Rectal 
examination  revealed  nothing.  It  was  thought  probable  that  the 
bell  had  lodged  in  the  oesophagus  and  had  worked  its  way  into  the 
surrounding  tissues  but  owing  to  the  long  time  which  had  elapsed, 
it  was  considered  dangerous  to  attempt  removal  with  instruments 


49 

introduced  through  the  mouth.  It  was  decided  to  explore  the 
abdomen,  making  incision  over  the  stomach  in  order  to  be  able  to 
reach  from  this  point  the  pylorus,  the  ileocaecal  valve  and  the  oeso- 
phagus. On  opening  the  abdominal  cavity,  pylorus  and  ileocaecal 
valve  were  examined,  and  afterwards  the  intestines,  but  the  bell 
could  not  be  found.  The  stomach  was  then  opened  near  the  cardiac 
end  and  finger  introduced  into  the  oesophagus.  Long  forceps  were 
extended  up  the  oesophagus,  but  nothing  found.  Oesophagotomy 
was  then  performed  ;  the  operation  being  rendered  very  difficult  by 
clusters  of  enlarged  cervical  glands  overlying  the  vessels  and  the 
oesophagus.  The  oesophagus  was  opened,  but  being  too  small  to 
permit  the  introduction  of  the  finger,  forceps  were  introduced  at 
the  same  time  from  above  and  below,  but.  nothing  could  be  felt  of 
the  foreign  body.  The  patient  was  in  a  very  weak  condition,  and 
it  was  thought  best  to  do  nothing  further.  The  opening  in  the 
stomach  was  closed  with  cat-gut,  and  abdominal  incision  with  silk- 
worm-gut sutures.  Th  eoesophageal  incision  was  packed  with  iodo- 
form gauze.  Child  was  very  weak  at  the  close  of  the  operation. 
Rallied  somewhat  about  4  p.  m.,  then  gradually  failed  and  died  at 
7  p.  m.  No  autopsy  could  be  obtained.  The  most  probable  explan- 
ation of  the  case  was,  that  the  bell  had  ulcerated  through  the  wall 
of  the  aesophagus. 

P.  F. — Incompleted  laparotomy  for  impacted  gall  stones. — Ameri- 
can ;  60  years  of  age ;  married  Had  previously  been  strong  and 
healthy.  Fifteen  years  ago,  while  in  Georgia,  had  a  severe  attack 
of  malarial  fever  and  passed  a  gall  stone.  Three  years  later  passed 
the  second  gall  stone  and  from  that  time  until  two  years  ago  has 
passed  gall  stones  at  intervals  varying  from  a  few  months  to  a  year. 
In  August  1891,  commenced  loosing  flesh.  Had  chills  every  few 
weeks,  followed  by  fever.  In  March,  1892,  Dr.  Maynarcl  of  Elyria, 
took  charge  of  the  case.  Since  that  time  the  stools  have  been  of  a 
grayish  white  color.  Patient  shows  marked  icterus.  The  attacks 
have  grown  more   frequent  and  have  been    accompanied  by  severe 


5Q 

pain.  The  attacks  usually  commence  with  a  chill,  with  an  increase 
of  temperature  during  the  attack  and  sub-normal  temperature  fol- 
lowing. Urine  contained  bile  during  the  attacks.  Dr.  Allen  was 
called  in  consultation  October  14th.  It  was  decided  to  make  an  ex- 
ploratory laparotomy.  Operation  was  performed  October  17th,  Dr. 
H.  A.  Tobey  of  Toledo  present.  Dr.  Maynard  gave  ether.  In- 
cision was  made  over  the  region  of  the  gall  bladder  parallel  to  the 
right  costal  cartilages.  On  opening  the  abdominal  cavity  the  omen- 
tum was  adherent  to  the  abdominal  walls  and  to  the  liver.  The 
intestines  were  firmly  adherent  to  the  under  surface  of  the  liver  and 
all  attempts  at  dissection  were  followed  by  considerable  hemorrhage. 
A  small  movable  mass,  presumably  a  gall  stone  could  be  felt,  but 
it  was  thought  unsafe  to  proceed  further  with  the  operation  owing 
to  the  firm  adhesions  and  hemorrhage.  The  peritoneum  was 
sutured  with  fine  and  the  abdominal  muscles  with  heavier  cat-gut. 
The  skin  was  united  with  silk  worm  gut  sutures.  The  patient  re- 
acted well  after  the  operation  and  went  on  to  an  uninterrupted  re- 
covery. A  few  stitch  abscesses  formed  but  closed  by  granulation. 
Since  the  operation  the  health  of  the  patient  has  been  much  im- 
proved. The  attacks  have  been  less  frequent  and  patient  has  gained 
much  in  flesh.  Notwithstanding  this  improvement  the  further  his- 
tory of  the  case  is  looked  upon  as  uncertain.  The  degree  of  im- 
provement which  has  been  secured  has  doubtless  been  due  to  the" 
breaking  up  of  adhesions. 


51 


ABDOMINAL  OPERATIONS. 

(not  laparotomies.) 


52 

ABDOMINAL  OPERATIONS  NOT  LAPAROTOMIES. 

Thirteen  operations,  including  two  operations  for  hernia,  two 
nephrectomies  and  two  nephrotomies,  one  perinephritic  abscess, 
one  fistula,  and  five  operations  upon  the  abdominal  walls,  includ- 
ing tumors,  and  minor  operations. 

Operations  for  hernia  ;  two  cases  ;  one  recovery,  one  death, 
following  strangulated  hernia. 

Case  I. — C.  K.  German  ;  21  years  of  age;  single.  Had  always 
been  healthy.  Has  had  a  right  inguinal  hernia  since  birth,  but 
never  caused  much  trouble  until  March,  1892,  when  it  came  down 
and  was  reduced  with  difficulty.  Has  tried  various  kinds  of 
trusses,  but  without  success.  Patient  also  had  a  hydrocele  on  the 
right  side.  Patient  sent  by  Dr.  F.  Fliedner.  Was  operated  at 
Charity  Hospital,  May  11th.  Incision  over  external  abdominal  ring. 
Intestines  were  easily  reduced.  Omentum  which  was  adherent  to  the 
sac  was  ligated  with  silk  and  stump  returned  to  abdominal  cavity  ; 
sac  also  ligated  and  cut  away.  Sutures  of  silver  wire  were  introduced 
through  the  pillars  of  the  ring,  the  ends  being  carried  up  through 
spirals  of  silver  wire  and  fastened  by  clamping  with  a  split  shot. 
These  sutures  are  easily  removed  by  cutting  away  the  shot  and 
pulling  out  the  spiral,  which  leaves  the  ends  of  the  silver  wire  free 
to  be  seized  and  withdrawn. 

Dissected  out  the  sack  of  the  hydrocele  and  also  removed 
two  small  hydroceles  of  the  chord.  Sewed  the  incision  with  silk; 
gauze  drainage.  Patient  made  an  uninterrupted  recovery;  Wire 
sutures  were  removed  May  22d.  There  was  some  superficial 
suppuration  and  wound  healed  by  granulation.  Patient  went  home 
June  11th.     Has  a  strong  scar  and  no  return  of  the  trouble. 

Case  II. — Mrs.  W.  German;  age  48  ;  always  been  health}-. 
Has  had  a  right  inguinal  hernia  for  several  years,  but  was  able  to 
control  with  a  truss.  On  March  20th,  hernia  came  down,  and  could 
not  be  reduced.  Dr.  C.  Sihler  was  called  and  advised  immediate 
operation,    but    patient    refused.     Several   attempts    were    made    at 


53 

reduction,  but  failed.  Patient  was  in  extreme  pain,  and  commenced 
vomiting  a  stercoraceons  material.  Was  taken  to  Lakeside  Hospital 
March  22nd.  Hernia  had  then  been  down  about  60  hours  and 
patient  finally  consented  to  operation.  On  opening  the  sac  con- 
siderable fluid  escaped.  The  gut  was  much  darkened,  but  regained 
its  color  somewhat  after  the  stricture  was  cut.  Patient  was  in  a 
very  weak  condition  and  it  was  thought  best  not  to  attempt  a 
resection,  their  being  a  fair  chance  that  the  intestine  would  not 
become  gangrenous.  Intestine  was  returned  to  abdominal  cavity 
and  the  sac  tied  and  cut  away.  The  ring  was  sewed  with  kangaroo 
tendon.  On  following  day  passed  flatus.  Temperature  ranged  be- 
tween IOOtj  and  101i ;  pulse  112  to  116.  On  third  day  obtained 
movement  of  the  bowels.  On  fifth  clay  patient  suffered  intense 
abdominal  pain  and  symptons  of  perforation  appeared.  Rapidly 
failed  and  died  on  fifth  day  after  operation.  A  post  mortem  exami- 
nation revealed  a  perforation,  with  escape  of  faecal  fluid  into  the 
abdominal  cavity,  causing  general  peritonitis. 


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Left  lumbar  nephro- 
tomy. 

Opened  abscess  of  kid- 
ney containing  sev- 
eral ounces  of  pus. 

Tamponed  with  iodo- 
form gauze. 

Opened  perinephritic 
abscess  of  right  side 
containing   2  quarts 
of  pus. 

Counter       opening 
through     the     back 
with  rubber  drainage 
tubes. 

Patient  in  a  septic 
condition. 

Sinus    from  former 
operation  discharg- 
ing slightly. 

FluctuatiHg    tumor 
filling    up    right 
lumbar  region. 

Microscopical       ex- 
amination of  urine 
showed  nothing  ab- 
normal. 

In  1888 developed  cys- 
titis;    had     pus    in 
urine;    Apr.  '92  sud- 
denly became  worse; 
had   fever    and   con- 
fined to  his  bed  eight 
weeks. (Dr.  Longhead 
performed      nephro- 
tomy   in    June,   and 
opened    an    abscess 
which    discharged 
profusely  for  a  time. 

Always  healthy;  June 
'92    received    injury 
over     right     lumbar 
region. 

Taken  sick  in  Septem- 
ber and  in  December 
developed  an  abscess 
in  right  side. 

July  ISth, 
1.892. 

Residence 

of 
Patient. 

Dec.  22d, 

1892. 

Residence 

of 

Patient. 

Dr.  B.  B. 

Longhead 

of 

Akron, 

Ohio. 

Dr.  H.  N. 

Fenton 

of 

Welshtield 

Ohio. 

Male. 
Married. 

Male. 
Married. 

1                    S 

< 

W.F.B. 

The  above  table  gives  five   eases   all   of    which   are   worthy    of 
mention  in  detail. 

Case  I. — E.J.  J- — Renal Calculi ;  Nephrectomy;  Recovery. — 
Health}-  until  three  years  ago,  when  she  strained  herself 
while  lifting.  Felt  sudden  giving  away  in  the  right  lumbar 
region,  and  was  taken  with  severe  pain.  Two  years  later,  in 
October,  1891,  while  getting  out  of  a  carriage,  fell  and  struck  on 
the  right  side  in  the  lumbar  region.  In  December,  1891,  had  a 
sudden  illness,  commencing  with  vomiting,  followed  by  a  chill 
and  fever.  During  this  illness,  had  sharp  shooting  pains  in  region 
of  right  kidney  and  discovered  a  tumor.  Dr.  Ryal  of  Wooster, 
diagnosticated  floating  kidney,  and  found  albumen  in  the  urine. 
Patient  was  sick  about  four  weeks.  In  January,  1892,  had  another 
attack,  which  came  on  gradually,  and  seemed  to  radiate  from  the 
right  kidney  over  the  entire  abdomen.  Severe  pain  lasted  two  or 
three  hours,  and  left  patient  greatly  prostrated.  During  this  at- 
tack, urine  was  observed  to  contain  pus.  Since  this  time  she  has 
had  several  similar  attacks,  but  not  so  severe.  Patient  has  been 
able  to  be  around,  but  could  not  attend  to  any  duties.  Has  had  a 
poor  appetite,  and  lost  flesh  rapidly.  Right  leg  flexed  during  the 
attacks,  and  causes  much  pain  in  straightening.  Dr.  Allen  first 
saw  patient  September  27th.  Confirmed  the  diagnosis  of  floating 
kidney,  and  ordered  urine  saved  for  examination.  September  29th, 
passed  41  oz.  of  urine  ;  September  30th,  33  oz  ;  October  1st,  21  oz  ; 
October  2nd,  41  oz;  October  3rd,  31  oz  Urine  was  loaded  with 
pus;  no  sugar,  and  after  filtration  through  charcoal  contained  no 
albumen.  October  24th  patient  entered  Charity  Hospital.  Could 
feel  a  movable  tumor  in  the  right  side  somewhat  larger  than  a 
normal  kidney.  Operated  October  27th.  Dr.  Lee  administered 
chloroform.  Made  lumbar  incision,  extending  vertically  from  the 
end  of  the  12th  rib  to  the  crest  of  ilium  ;  colon  presented  itself  in 
the  incision  The  kidney  found  and  brought  out  through  the  in- 
cision Could  feel  concretions  in  its  interior,  of  such  a  size  that  it 
was  unwise  to  attempt  to  remove  them  and  save  kidney.      Was  re- 


57 

moved  entire  and  the  pedicle  ligated  with  silk.  The  ureter  was 
disinfected  with  bi-chloride  and  the  cut  end  sutured  with  cat-gut. 
Wound  was  tamponed  with  iodoform  gauze,  the  ends  of  the  incision 
being  sewed  with  silkworm-gut.  The  kidney  was  somewhat  larger 
than  normal,  and  on  incising  was  found  to  contain  two  calculi, 
making  a  perfect  mold  of  the  pelvis.  The  ureter  was  completely 
occluded  by  a  calculus.  The  kidney  contained  considerable  pus, 
and  in  on  place  suppuration  had  extended  nearly  to  the  surface. 
Patient  reacted  well  after  operation.  The  first  dressing  was  made 
on  the  fourth  day  ;  gauze  tampon  removed.  On  November  6th 
and  7th  the  temperature  rose  to  102.  November  8th  dilated  sinus ; 
syringed  out  considerable  pus  and  introduced  rubber  drainage  tube. 
November  20th  drainage  tube  was  removed.  November  21st  had  a 
slight  attack  of  pleurisy  lasting  a  few  days.  The  patient  was 
subject  to  frequent  headaches,  which  were  always  associated  with  a 
diminution  in  amount  of  urine  secreted.  Left  hospital  Dec.  18th. 
Patient  is  now  in  excellent  health.  Urine  contains  no  pus.  The 
following  table  gives  the  results  of  daily  urinary  analyses  made  by 
Dr.  P.  Max  Foshay. 


WEEKLY    AVERAGES. 


WEEK. 

URINE. 

SOLIDS. 

UREA. 

RATIO  OF    TREA 
TO    SOLIDS. 

NOV 

c.  c. 
949 

GRM. 

GRM 

7—13 

15.14 

14—20 

1268 

37.78 

17.25             1:2.7 

21-27 

793 

47.70 

13.35 

1:3. 

28- Dec.  4 

983 

45.33 

14.00 

1:2.8 

5—11 

684 

27.30 

10.10             1:2.4 

12—16 

919 

29.03 

12.41 

1:2.4 

59 


» 

CASE- II. — L-  K.  Pyelonephrosis  ;  Nephrectomy;  Recovery. — 
American,  26,  married.  Was  a  weak,  delicate  girl  until  eight- 
een years  old.  Menses  first  appeared  at  15,  irregular  and 
scant)'.  After  three  years  became  regular.  Married  at  20. 
Confined  at  21.  Had  normal  labor.  When  child  was  three  months 
old,  patient  began  to  be  troubled  with  frequent  micturition,  and 
smarting  in  the  urethra  and  bladder,  which  increased  in  severity, 
and  urine  became  full  of  pus  and  mucus.  Examination  revealed 
an  inflamed  urethra,  uterus  retroflexed,  cervix  lacerated  and  endome- 
tritis. Uterus  was  curetted  and  cervix  repaired-  Patient  improved 
in  general  health,  but  pain  in  the  urethra  and  bladder  continued. 
Bladder  was  washed  with  boracic  acid  solution,  with  some  improve- 
ment Became  pregnant  about  November  1st,  1*91 ;  miscarried 
December  20th.  Had  fever  and  considerable  hemorrhage.  Uterus 
was  curetted  and  washed  out,  followed  b\r  speed}'  recovery.  July 
5th,  1892,  patient  received  a  blow  on  the  left  side  below  the  border 
of  the  ribs.  Severe  pain  followed  in  left  lumbar  region.  From 
this  time  on  until  September  9th,  patient  had  fever,  accompanied  by 
severe  pain  in  left  side  A  fluctuating  tumor  developed.  Patient 
was  in  a  very  weak  condition.  Pulse  about  140;  temperature  104. 
Daily  chills,  diarrhoea  and  vomiting.  Urine  scanty  and  full  of  pus. 
On  September  9th,  1892,  the  kidney  was  incised  by  Dr.  W-  H. 
Humiston,  with  a  discharge  of  about  eight  ounces  of  pus.  Drainage 
tube  was  inserted.  The  discharge  continued  free  for  a  few  days 
and  gradually  subsided.  Temperature  returned  to  normal  and 
patient  improved  rapidly.  Urine  still  contained  pus,  however,  and 
there  was  a  discharge  of  urine  thiough  the  incision.  On  this  ac- 
count Dr.  Allen  was  called  in  consultation  and  operated  January 
18th,  1893,  at  Dr.  Humiston's  Hospital.  It  having  been  first  de- 
termined that  sufficient  urea  was  being  excreted  by  the  right  kidney. 
Dr.  Foshay  administered  the  chloroform.  The  incision  was  made 
from  the  12th  rib  downward  to  the  crest  of  the  ilium.  The  sinus 
remaining  from  the    former  operation  \va.^  dissected  out.     The  kid-' 


62 


ney  presented  itself  in  the  wound,  but  owing  to  its  great  size  and 
dense  adhesions,  could  not  be  removed  through  so  small  an  opening. 
A  transverse  incision  was  then  made,  and  kidney  dissected  out 
with  great  difficulty.  The  peritoneal  cavity  was  twice  opened,  but 
was  immediately  closed  with  fine  cat-gut  Pedicle  was  ligated 
with  silk  and  kidney  removed.  The  wound  wis  tamponed  with 
iodoform  gauze  ;  the  ends  of  the  incision  being  sewed  with  silk. 
The  kidney  was  about  three  times  normal  size,  and  interior  was 
full  of  abscesses.  Patient  reacted  nicely  after  the  operation.  The 
iodoform  gauze  was  removed  on  the  fourth  day.  Had  considerable 
tympanites  on  the  third  day.  On  fourth  day,  temperature  went  to 
102.  Gave  Rochelle  salts  and  enema,  causing  good  movement. 
From  this  time  on,  the  patient  improved  and  left  the  hospital  March 
4th.  The  wound  was  entirely  healed  about  eight  weeks  after  the 
operation.  Patient  is  now  in  excellent  condition  and  has  no  further 
trouble. 

The  following  table  gives  the  results  of  daily  urinary  analyses 
by  Dr.  P.  Max  Foshay: 

WEEKLY    AVERAGES. 


WEEK. 

URINE. 

SOLIDS. 

UREA. 

RATIO  OF    URKA 
TO  SOLIDS. 

Jan. 

c.  c. 

GRM. 

GRM. 

19—25 

690 

3699 

16.03 

1:2.3 

26— Feb.   1 

1271 

43.72 

19.98 

1:2.2 

2—8 

1385 

50.77 

18.05 

1:3.1 

9—15 

1071 

38.41 

14.76 

1:2.6 

16—22 

1275 

38.91 

14.44 

1:2.7 

23—28 

1283 

53.20 

18.29 

1:2.9 

63 

CASE  III. — G.  H.  W.  Abscess  of  the  Kidney  ;  Nephrotomy  ;  Re- 
covery.—  Was  quite  healthy  as  a  child  ;  always  been  very  nervous. 
Eight  years  ago  had  a  serious  attack  of  renal  colic,  and  urine  con- 
tained albumen  and  casts.  Three  years  ago,  went  to  Carlsbad  and 
took  a  course  of  treatment.  Remained  abroad  one  year,  and  returned 
much  improved.  In  the  spring  of  1892,  patient  commenced  to  run 
down  and  lost  considerable  flesh.  September  2,  1892,  Dr.  Noble, 
of  Oberlin,  was  called  to  attend  the  patient.  Physical  examination 
showed  a  tumor  in  the  left  lumbar  region.  Patient  complained  of 
severe  pain  referred  to  the  region  of  the  left  kidney  and  bladder. 
The  urine  was  loaded  with  pus.  During  the  following  five  days 
the  morning  temperature  was  normal  ;  evening  temperature  about 
103.  The  patient  was  very  weak.  Could  take  no  nourishment, 
and  was  kept  up  on  stimulants.  Dr.  Allen  was  called  to  Oberlin, 
September  6th.  Operated  September  7th.  The  entire  left  lumbar 
region  was  dull,  with  distinct  fluctuation  over  tumor.  Dr.  Noble 
administered  the  chloroform.  A  vertical  incision  was  made  from 
the  ends  of  the  floating  ribs  to  the  crest  of  the  ilium.  Opened  an 
abscess  containing  about  two  quarts  of  thick  bad  smelling  pus, 
together  with  shreds  of  kidney  tissue.  Walls  of  the  abscess  cavity 
were  rough  and  bled  easily.  Irrigated  thoroughly  with  water  and 
tamponed  with  iodoform  gauze.  Patient  was  very  weak  after  the 
operation  but  reacted  well.  The  tampon  was  removed  on  the  third 
day,  and  abscess  cavity  was  daily  irrigated  with  boracic  acid  solu= 
tion-  The  temperature  ranged  from  normal  in  the  morning  to  99  in 
the  evening.  During  the  following  month  the  general  com  ition  of 
the  patient  was  much  improved.  In  November,  1890,  the  patient 
took  a  bad  turn  ;  became  extremely  restless.  Had  some  fever  at 
night,  and  commenced  losing  flesh  again.  The  urine  had  smelled 
strongly  of  iodoform,  and  owing  to  the  daily  packing  of  the  wound 
with  iodoform  gauze  it  was  thought  that  perhaps  the  condition 
might  be  due  to  iodoform  poisoning.  Then  commenced  washing 
the  cavity  with  peroxide  of  hydrogen,   and  used  plain  gauze  as  a 


64 

tampon.  About  Christmas  the  patient  commenced  improving  The 
discharge  has  gradually  diminished.  Some  pus  still  present  in  the 
urine,  but  in  very  small  quantities.  Patient  has  slowlj7  but  steadily 
improved  up  to  the  present  time. 

Case  IV — Dr.  W.  F.  B.  Tubercular  Pyelonephrosis ;  Nephro- 
tomy ;  Death  in  3)4  months. — The  father  of  the  patient  died  of 
pmlmouary  tuberculosis  in  1889,  the  mother,  of  the  same  disease,  in 
February,  1891.  The  patient  was  perfectly  well  until  the  fall  of 
188.S,  when  he  commenced  having  pain  in  the  region  of  the  bladder, 
accompanied  by  painful  micturition.  The  urine  contained  consid- 
erable mucus  and  pus.  The  patient  was  treated  for  inflammation  of 
the  bladder,  and  at  times  was  much  better,  but  the  symtoms  finally 
became  so  severe  that  he  could  not  attend  to  his  duties  and  aban- 
doned his  practice  in  the  spring  of  1890.  At  this  time  he  came 
under  the  care  of  Dr.  B.  B.  Faughead,  of  Akron.  Microscopic 
examination  of  the  urine  showed  an  abundance  of  pus,  but  no  casts 
In  April,  1892,  the  patient  was  suddenly  taken  with  a  severe  chill, 
followed  by  fever,  and  was  confined  to  his  bed  about  eight  weeks, 
having  continual  fever  with  occasional  chills.  During  this  time 
pus  was  constantly  present  in  his  urine.  In  June,  1891,  a  fluctu- 
ating tumor  was  discovered  in  the  left  lumbar  region.  This  was 
opened  and  drained,  the  discharge  at  times  being  very  profuse. 
The  patient's  general  condition  steadily  grew  worse,  and  Dr.  Allen 
was  called  in  consultation  July  FSth.  The  patient  had  been  having 
a  rise  in  temperature  every  evening,  and  it  was  thought  best  to 
establish  better  drainage.  Nephrotomy  was  performed.  A  large 
abscess  was  found  in  the  left  kidney,  and  was  tamponed  with 
iodoform  gauze.  The  patient  improved  somewhat  for  a  time  after 
the  operation,  then  chills  and  fever  returned.  The  patient  failed 
and  died  of  exhaustion,  October  30,  1898.  Post  mortem  the  follow- 
ing day  showed  the  left  kidney  entirely  broken  down  and  in  a  sup- 
perating  mass.  Tubercular  deposits  were  found  upon  the  mesen- 
terv  of  the  descending  colon,  alone:  the  ureter,  and  on  the  base  of 


65 

the  left  lung.  The  right  kidney  was  congested  ;  the  bladder  was 
contracted  and  walls  very  much  thickened.  The  other  organs  were 
normal. 

Case  V. — P.  R.  Pcrinephritic  Abscess;  Recovery. — The  patient 
was  a  stout  man  ;  never  had  any  severe  illness.  Received  a  blow 
on  the  right  lumbar  region  in  June  of  1892  ;  the  injury  causing  him 
no  particular  trouble  at  the  time.  About  September  22nd,  com- 
menced feeling  badly,  but  was  not  confined  to  his  bed  until  October 
13th.  Patient  complained  of  pain  in  the  right  lumbar  region,  and 
walked  bent  over  to  the  right  side.  At  this  time  no  enlargement 
was  discovered.  November  3,  1892,  Dr.  H.  N.  Fenton,  of  Welsh- 
field,  took  charge  of  the  case.  The  bowels  were  regular,  stools  of 
somewhat  clayish  color.  Urine  was  dark,  but  at  no  time  contained 
albumen  or  pus.  The  evening  temperature  at  this  time  ranged 
from  101  to  102  y2 ',.  The  patient  steadily  grew  worse  until  about 
the  first  week  in  December,  when  a  fullness  was  discovered  in  the 
right  lumbar  region.  The  pain  at  this  time  was  not  so  severe. 
Temperature  at  night  about  102  ;  pulse  96.  Dr.  Allen  was  called 
in  consultation  December  18th.  Could  distinguish  an  enlargement 
in  the  right  lumbar  region,  extending  upward  toward  the  liver,  and 
downward  into  the  right  iliac  region.  Fluctuation  was  distinct. 
Operation  was  advised  and  performed  December  22nd.  Dr.  Fenton 
administered  the  chloroform.  Incision  was  made  perpendicular 
from  the  floating  ribs  to  the  crest  of  the  ilium.  Opened  an  abscess 
containing  two  quarts  of  pus.  At  the  bottom  of  this  abscess  the 
kidney  could  be  felt.  Made  a  counter-opening  at  the  outer  border 
of  the  quadratus  lumborum  muscle,  and  introduced  two  rubber 
drainage  tubes  extending  through  both  incisions.  Irrigated  thor- 
oughly, and  packed  the  cavity  with  iodoform  gauze.  Patient 
reacted  well  after  the  operation.  The  gauze  was  removed  on  the 
second  day  and  cavity  daily  washed  with  boracic  acid  solution. 
Discharge  rapidly  diminished,  and  temperature  returned  to  normal 
soon  after  the  operation.     Early  in  January,  one  of  the  drainage 


66 

tubes  was  removed  and  two  weeks  later  the  second,  and  gauze 
drainage  substituted.  The  patient  made  a  rapid  recovery,  and  was 
entirely  healed  the  latter  part  of  February. 


■_67_ 
OPERATIONS  FOR  TUMORS  NOT  ABDOMINAL. 


Operations  upon  the  breast 15 

Sarcoma  of  parotid 2 

Tumor  of  thyroid 1 

L,ympho  sarcoma  of  cervical  glands , 3 

Tubercular  lymphoma  of  cervical  gl  ands 7 

Melanotic  sarcoma  (sub  inqual  gland  and  neck) 1 

Carcinoma  cervical  glands 1 

Carcinoma  of  face  and  nose 1 

Epithelioma  of  the  lip 1 

Fibroid  tumor  of  tongue 1 

Epulis 1 

Multiple  atheroma  of  scalp  (cases) 2 

Atheroma  of  face 1 

Naevi 3 

Carcinoma  of  rectum 1 

Carcinoma  of  cervix 1 

Sarcoma  of  testicle 1 

Lymphomata  of  groin 3 

Tumor  of  thigh  (sarcoma) 1 

Lipoma 1 

Tumors  (upper  extremity) 4 

TUMORS    OF    THE    BREAST 

Fifteen  operations.  One  case  of  a  tumor  occurring  in  a  man. 
Eight  operations  were  performed  for  carcinoma,  three  for  sarcoma, 
four  for  cysto- adenoma.  The  axilla  was  involved  in  ten  cases, 
and  the  contents  removed,  together  with  the  entire  breast.  In  two 
cases  the  breast  alone  was  removed.  In  four  cases  the  pectoralis 
major  muscle  was  removed  with  the  growth.  In  four  cases 
Thiersch's  transplantation  was  made  upon  the  fresh  wound.  In 
two  cases  the  skin  was  so  tightly  drawn  that  the  stitches  cut  through, 


68 

allowing  the  flaps  to  retract  and  the  wound  healed  by  granulation. 
After  two  operations  there  was  local  return,  and  after  one  operation, 
secondary  deposits  in  the  liver  occurred.  Ether  was  used  as 
anaesthetic  in  all  cases.  The  usual  antiseptic  precautions  were 
observed  during  the  operation,  distilled  water  being  used  for  irri- 
gation. In  four  cases  suppuration  of  the  skin  had  occurred  before 
operation.  In  these  cases,  after  disinfecting  the  skin  the  sup- 
purating mass  was  covered  with  iodoform  gauze  during  the  oper- 
ation. The  breast  was  first  removed,  all  bleeding  stopped,  and  the 
surface  covered  with  an  aseptic  towel.  The  axillary  incision  was 
then  extended  and  axillary  vein  exposed.  A  careful  dissection  of 
the  azilla  was  then  made,  extending  to  the  clavicle  and  under  the 
pectoralis  minor  muscle.  A  continuous  cat-gut  suture  was  employ- 
ed in  three  cases,  continuous  sutures  of  silk  being  used  in  the  other 
cases.  In  seven  cases  no  drainage  whatever  was  employed  and  the 
wounds  healed  by  first  intention.  In  three  cases  where  suppuration 
had  occurred  before  the  operation  a  rubber  drainage  tube  was  inserted 
in  the  axilla.  During  the  suturing  of  the  incision  the  flaps  were  closely 
compressed  to  the  chest  wall  to  prevent  any  oozing  of  blood.  An 
antiseptic  dressing  was  then  applied  and  the  arm  firmly  fixed  to 
the  chest  walls  by  gauze  and  starch  bandages.  The  first  dressing 
was  usually  made  on  the  seventh  day,  and  the  stitches  removed. 
When  Thierschs'  transplanation  was  made,  the  grafts,  which  at  the 
operation  had  been  covered  with  rubber  protective,  were  found  in 
every  case  to  be  firmly  adherent,  and  were  dressed  with  gauze 
moistened  in  a  solution  of  tincture  of  myrrh. 


69 


TUMORS  OF  THE  BREAST. 


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Case  VII. — C.  S.  A  healthy  farmer,  weighing  about  200  lbs. 
No  family  history  of  cancer.  Since  patient  can  remember,  there  has 
always  been  a  small  lump  in  the  left  breast,  about  the  size  of  a  pea. 
Never  caused  him  any  trouble  until  about  four  years  ago,  when  the 
tumor  became  somewhat  inflamed  from  carrying  heavy  boxes  in  his 
arms.  Increased  in  size  a  little,  and  then  seemed  to  return  to  its 
former  size.  Shortly  afterwards  it  commenced  growing  again,  and 
in  June,  1889,  was  about  the  size  of  a  walnut.  The  tumor  was 
removed  about  this  time,  but  commenced  growing  again  in  about 
three  months  after  the  operation  Was  operated  the  second  time  in 
October,  1 890.  Tumor  was  about  the  size  of  a  fist.  In  both  operations 
the  skin  over  the  tumor  was  not  removed.  The  growth  reappeared 
in  about  two  weeks,  and  steadily  increased  in  size.  About 
Christmas,  1891,  had  reached  the  size  of  two  fists.  The  skin  ulcer- 
ated, and  an  extremely  offensive  discharge  continued  until  the  opera- 
tion. About  this  time  the  patient  came  under  the  care  of  Dr.  G 
C.  L,athrop,  of  Dover,  and  had  a  severe  attack  of  influenza,  which 
delayed  the  operation.  Pyoktanin  was  injected  into  the  growth, 
but  caused  severe  pain,  and  the  treatment  was  discontinued.  The 
patient  did  not  fully  recover  from  the  influenza  until  the  following 
summer.  Was  first  seen  by  Dr.  Allen  July  5th,  1892.  The  growth 
was  about  the  size  of  three  or  four  fists,  firmly  fixed  on  the  thoracic 
wall,  and  ulcerated  in  numerous  places-  Patient  had  of  late  lost 
considerable  flesh,  and  was  greatly  annoyed  by  the  extremely  offen- 
sive discharge.  The  patient  begged  for  an  operation  at  any  risk. 
Operated  July  8th,  1892.  Removed  the  entire  mass,  together  with 
the  pectoralis  major  muscle,  down  to  the  ribs.  The  axillary 
glands  were  not  involved.  The  tumor  had  extended  into  the  inter- 
costal spaces  between  the  fourth,  fifth  and  sixth  ribs,  and  these 
portions  of  the  growth  could  not  be  removed  without  a  prolonged 
operation,  which  the  patient  was  too  weak  to  endure.  Made 
Thierschs'  transplantation  of  skin  from  the  anterior  surface  of  the 
thigh,    and  covered  the  entire  wound  with  the  exception  of  the 


73 

diseased  portions.  At  the  end  of  the  operation  the  patient  was  in 
severe  shock.  Was  stimulated  freely  by  hypodermic  and  rectal  injec- 
tions, and  in  the  evening  his  condition  was  considerably  improved 
On  the  following  day  the  patient  became  delerious,  and  was  very 
restless.  During  the  night  he  became  violent,  and  tore  off  the 
dressings  down  to  the  silk  protective  covering  the  skin  grafts.  The 
dressings  were  replaced,  but  on  the  following  morning  were  soaked 
with  a  bloody,  serous  discharge,  so  profuse  as  to  wet  all  the  bed- 
ding. The  patient  remained  in  this  condition  about  a  week- 
Dressings  were  changed  every  day,  and  were  completely  saturated 
with  a  thin,  bloody  discharge.  Stimulation  and  nourishment  were 
given  by  the  rectum.  July  18th  the  patient  commenced  to  improve. 
All  the  grafts  adhered,  and  on  July  28th  the  patient  went  home, 
the  wound  entirely  healed,  with  the  exception  of  a  few  points  of 
granulation,  and  the  portions  from  which  the  tumor  could  not  be 
entirely  removed.  The  patient  gained  flesh  rapidly  during  the 
summer  ;  was  able  to  oversee  his  farm  work,  and  assisted  in  some 
of  the  lighter  work.  The  movements  of  the  arm  were  perfect, 
with  the  exception  of  the  raising  of  the  arm  above  the  horizontal. 
In  the  latter  part  of  August,  the  nodules  again  commenced  grow- 
ing, and  were  treated  by  Dr.  Dathrop  with  pyoktanin,  but  without 
much  success.  Patient  returned  to  the  hospital  September  25th, 
and  on  the  following  day  the  nodules  were  curetted,  and  the  bases 
burned  with  the  Pacquelin  cautery.  The  patient  remained  in  the 
hospital  about  a  week.  During  the  following  winter  the  nodules 
increased  somewhat  in  size.  The  patient  still  enjoys  good  health, 
and  is  at  present  considering  an  operation  for  the  removal  of  the 
ribs  involved  by  the  growth.  Microscopic  examination  showed  the 
tumor  to  be  a  sarcoma. 

Case  XIV. — L,.  G.  S.  Patient  has  always  been  healthy  No 
history  of  cancer  in  the  family.  Was  confined  13  years  ago  and 
had  no  trouble  with  the  breast  at  that  time.  Was  confined 
the  second  time  in   October,   1892.      Previous  to  confinement  the 


74 

patient  observed  that  the  left  breast  was  hard,  and  that  the  nipple 
was  retracted.  Had  some  pain  of  a  neuralgic  character.  Dr.  Allen 
first  saw  the  patient  about  January  1st,  1893.  Both  breasts  were 
large  and  secreted  an  abundance  of  milk.  A  diagnosis  at  that  time 
could  not  positively  be  made  and  advised  the  use  of  an  elastic 
bandage  to  dry  up  the  secretion  of  milk  The  patient  returned 
January  26th.  Operated  February  1st.  First  incised  the  tumor, 
which  was  of  a  hard  consistence,  and  had  the  macroscopic  appear- 
ences  of  a  carcinoma.  The  entire  breast  was  removed  together 
with  the  pectoralis  major  muscle,  to  which  it  was  firmly  adherent. 
The  axillary  glands  were  involved,  and  removed.  Thierschs' 
transplantation  was  made  from  the  anterior  surface  of  the  thigh. 
The  outer  extremities  of  the  incision  were  brought  together  with 
silk  sutures.  The  patient  reacted  well  after  the  operation.  On  the 
sixth  day  the  first  dressing  was  made  ;  all  the  grafts  were  in  place. 
Patient  did  nicely  for  about  10  days  after  the  operation,  then  com- 
menced having  severe  pain  in  the  sides.  The  pains  were  so 
severe  that  hypodermics  of  morphia  were  required  The  patient 
was  finally  able  to  sit  up  a  few  hours  each  day.  Physical  examin- 
ation showed  no  trouble  in  the  thoracic  cavity.  The  patient  was 
treated  for  rheumatism  but  steadily  grew  worse  and  was  confined  to 
her  bed.  About  this  time  it  was  noticed  that  the  liver  was  becom- 
ing enlarged  Patient  has  returned  home,  but  is  gradually  failing. 
Undoubtedly  has  secondary  deposits  in  the  liver.  Microscopic 
examination  showed  the  tumor  to  be  a  carcinoma  with  large 
alveoli  and  little  connective  tissue,  presenting  the  characteristic 
appearance  of  the  most  malignant  of  tumors 


75 


77 


MISCEELANEOUSE   CASES- 


Among  the  miscellaneous  cases,  the  following  are  worthy  of 
mention : 

Case  I. — Sarcoma  of  the  Parotid.  J.  G.  W.  C-  American; 
age  56  ;  male.  The  patient  has  always  been1  a  healthy  man.  About 
25  years  ago  had  periositis  of  the  lower  jaw  and  while  the  inflam- 
mation was  still  present,  he  received  an  injury  in  the  region  of  the 
left  parotid.  A  tumor  soon  developed  and  grew  slowly  until  it  was 
about  the  size  of  a  walnut  and  then  remained  stationary  during 
several  years.  Consulted  surgeons  in  New  York  and  in  this  city 
about  10  years  ago,  and  was  advised  against  removal  of  the  tumor 
on  account  of  the  danger  of  injuring  the  facial  nerve.  During  the 
last  few  years  the  tumor  has  steadily  grown,  and  the  patient 
consulted  Dr.  Allen  from  time  to  time.  The  tumor  finally  attained 
the  size  of  a  hen's  egg.  Operation  advised  and  performed  Jul}-  5th, 
1892.  Dr.  H.  K.  Cushing  administered  the  anaesthetic.  A 
cystic  tumor  was  removed  with  a  portion  of  the  parotid  gland.  The 
skin  was  sutured  with  silkworm-gut,  with  cat  gut  drainage  at  the 
lower  end.  The  wound  healed  by  first  intention  A  slight  serous 
discharge  continued  through  the  sinus  for  about  10  days.  None  of 
the  branches  of  the  facial  nerve  were  injured  by  the  operation,  and 
the  patient  has  since  had  no  return  of  the  trouble.  Microscopic 
examination  made  by  Prof.  W.  H.  Welsh,  of  Johns  Hopkins  Uni- 
versity, showed  the  tumor  to  be  a  cysto-chondro-sarcoma. 

Case  II. — Sarcoma  of  the  Parotid.  L,.  B.  American,  female, 
age  36  ;  single.  Had  always  been  rather  delicate.  Four  years  ago 
fell  down  stairs  and  bruised  the  left  side  of  her  face.  About  a  year 
later  noticed  a  small  tumor  in  region  of  the  left  parotid ;  this  grew 
very  slowly  for  a  time  but  during  the  last  year  increased  rapidly  and 
became  the  size  of  two  walnuts.  Within  the  last  five  or  six  months 
has  had  some  slight  pains.  Operated  November  16, 1892,  at  Charity 
Hospital.     Removed   tumor  together  with  a  portion  of  the  parotid 


73 

gland.  Sewed  incision  with  silkworm-gut  sutures  and  introduced 
cat-gut  drainage  in  lower  end.  Sutures  removed  on  fifth  day. 
Healing  had  taken  place  by  first  intention.  Some  fluid  had  accum- 
ulated in  the  cavity  left  by  removal  of  tumor  and  was  discharged. 
Wound  continued  to  run  a  considerable  fluid  for  two  weeks.  This 
was  examined  and  found  to  be  saliva.  Discharge  gradually  dimin- 
ished and  was  entirely  healed  in  about  three  weeks.  There  has 
been  no  return  of  the  trouble.  Microscopical  examination  showed 
the  tumor  to  be  a  sarcoma. 

Case  III. — Melanotic  sarcoma  of  neck  developing  in  a  birth 
mark — Recovery  ;  local  recurrence  in  seven  months.  H.  T.  American 
61  Has  always  been  healthy  ;  since  birth  had  a  small  mark  on  left 
side  of  neck,  about  the  size  of  a  thumb  nail-  This  gave  him  no 
trouble  until  about  three  years  ago  when  it  commenced  spreading,  and 
in  two  years  had  reached  the  size  of  a  dollar.  During  the  last  year 
has  spread  somewhat  more  irregularly.  In  June,  1892,  a  lump — size 
of  a  hickory  nut — developed,  and  soon  afterwards  numerous  smaller 
dots  in  the  region  of  the  discoloration.  About  August  1st  the  skin 
ulcerated  and  frequently  bled.  Consulted  Dr.  Allen  Sept.  13th- 
The  discoloration  had  then  spread  downward  nearly  to  the  clavicle 
and  anteriorly  to  the  median  line  under  the  chin.  The  color  was  of 
a  very  dark  blue,  with  numerous  small  black  points.  Below  the 
angle  of  the  jaw  was  an  ulcerating  mass,  projecting  about  an  inch. 
Operation  was  performed  Sept.  15th  The  discolored  portion  of  the 
skin  was  cut  away.  Numerous  small  black  bodies  about  the  size  of 
millet  seeds  extended  deeper  in  the  subcutaneous  tissues  of  the  neck; 
new  points  constantly  appearing  as  the  dissection  proceeded.  The 
sub-lingual  gland  was  enlarged  and  full  of  black  points,  and  was 
removed.  The  cervical  glands  were  also  found  to  be  involved,  and 
were  dissected  out,  and  what  appeared  in  the  beginning  to  be  a 
simple  operation,  developed  into  a  most  difficult  one.  The  ends  of 
the  incisions  were  brought  together  with  silk  sutures ;  the  central 
portion  left  to  heal  by  granulation.     The  patient  made  a  good  re- 


79 

covery,  and  was  entirely  well  in  about  six  weeks.  Microscopic  ex- 
amination was  made  by  Dr.  I.  N.  Himes,  and  by  Dr.  G.  C.  Free- 
born, of  the  College  of  Physicians  and  Surgeons,  of  New  York  city, 
and  tumor  pronounced  to  be  a  melanotic  sarcoma.  The  tumor  re- 
turned locally  in  the  cicatrix  in  April,  1892,  and  has  since  been 
operated  a  second  time.  No  tumors  have  developed  in  any  other 
portion  of  the  body. 

Case  IV. —  Tumor  of  the  Thyroid.  K.  G.  German,  age  28, 
single.  Patient  has  always  enjoyed  good  health.  About  two  years 
ago  noticed  small  lump  in  region  of  the  thyroid  gland.  This 
steadily  increased  until  about  the  size  of  a  hickory-nut,  and  has 
since  remained  stationary.  The  tumor  was  very  hard,  and  gave 
the  patient  no  annoyance  beyond  a  pressure  and  inconvenience 
when  singing,  causing  her  to  sing  fiat  in  her  upper  register. 
Operation  was  performed  July  24th,  and  a  hard,  calcareous  tumor 
was  removed  from  the  substance  of  the  thyroid  gland-  The  incision 
was  closed  with  silkworm-gut  sutures,  with  gauze  drainage.  Some 
slight  discharge  continued  for  about  two  weeks  after  the  operation. 
Sinus  then  closed  and  patient  had  no  further  trouble. 

Case  V. — Secondary  deposit  in  Cervical  Glands  following  an 
operation  for  Carcinoma  of  the  Tongue.  Recovery,  recurrence  in 
three  months.  J.  S.,  American,  age  57.  No  history  of  cancer  in 
family.  About  two  years  ago  had  portion  of  his  tongue  removed 
for  a  malignant  growth.  Soon  after  the  operation,  patient  noticed 
an  enlargement  in  the  neck.  This  has  steadily  increased  in  size, 
and  of  late  has  caused  him  much  pain.  Dr.  Allen  first  saw  the 
patient  July  6th.  The  left  half  of  the  tongue  had  been  removed, 
and  clusters  of  hard  undurated  glands  were  to  be  felt  on  the  left 
side  of  the  neck.  The  tumor  was  but  slightly  movable  and 
extended  deep  into  the  neck.  The  patient  was  very  anxious  that 
an  operation  should  be  performed  at  any  risk.  Pain  had  been  very 
severe  of  late,  and  the  patient  had  lost  considerable  flesh.  An  opera- 
tion was  performed  July  9th.     The  tumor  was  firmly  adherent  to 


I 

: 
80 


the  sheaths  of  the  vessels  posteriorly,  and  during  the  dissection 
the  internal  jugular  was  twice  opened,  necessitating  its  ligation 
above  and  below.  The  wound  was  closed  with  silk  sutures  with  gauze 
drainage  at  the  lower  angle.  The  patient  made  a  good  recovery 
and  his  general  health  improved.  In  August  patient  received  a 
blow  on  the  neck,  followed  by  suppuration  and  discharge  of  pus 
through  the  lower  end  of  the  incision.  The  induration  following 
the  abscess  did  not  subside.  The  tumor  again  developed,  and  in 
November  ulceration  of  the  skin  occurred.  The  patient  is  still 
alive 

Case  VI. — Carcinoma  of  the  Rectum.  Removal,  recovery,  no 
recurrence  Mrs.  S-,  age  58.  No  history  of  cancer  in  the  family. 
For  a  number  of  years  has  been  greatly  troubled  by  hemorrhoids. 
During  the  last  year  has  noticed  that  with  every  movement  cf  the 
bowels,  a  pedunculated  mass  was  pressed  through  the  sphincter  and 
returned  into  the  bowel  with  difficulty.  Of  late  this  mass  has 
increased  considerably  in  size.  The  surface  became  ulcerated  and 
the  pain  more  severe.  Operation  was  performed  May  13th.  The 
sphincter  was  dilated  and  the  pedunculated  mass,  about  the  size  of  an 
English  walnut  prolapsed  from  the  bowel.  The  pedicle  was  about  the 
size  of  a  lead  pencil  and  about  half  an  inch  long.  Was  ligated 
and  the  growth  removed.  Allingham's  operation  was  then  per- 
formed upon  the  hemorrhoids.  The  patient  made  a  good  recovery, 
and  has  since  had  no  return  of  her  trouble.  Microscopic  examina- 
tion showed  the  tumor  to  be  a  carcinoma.  The  case  is  quite 
remarkable,  since  the  projecting  mass  which  had  the  appearance 
of  a  portion  of  prolapsed  bowel,  showed  under  the  microscope 
typical  alveoli  filled  with  epithelial  cells. 

Case  VII. — Carcinoma  of  the  Cervix.  G.  B.  Curetting.  N  o 
history  of  milignant  disease  in  the  family.  The  patient  con- 
sidered herself  perfectly  well  until  about  four  months  before  the 
operation,  when  she  noticed  a  bad  smelling  discharge.  Was  treated 
locally,  but  the  discharge    steadily    increased.     First   consulted  Dr. 


8i 

Allen  May  11th.  The  entire  surface  was  ulcerated  and  the  vault  of 
the  vagina  indurated  with  the  growth.  Vaginal  hysterectomy  was 
out  of  the  question,  but  the  patient  desired  some  relief  from  the  ex- 
tremely offensive  discharge.  May  13th  the  mass  was  thoroughly 
curetted  and  burned  with  a  Pacquelin  cautery.  The  patient  had  no 
pain  after  the  operation  and  left  the  hospital  in  about  ten  days.  In 
August  the  discharge  again  commenced  and  the  patient  rapidly  failed 
and  died  in  October,  1892. 

Case  VIII. — Sarcoma  of  the  Testicle.  Removal.  No  recurrence. 
H.  C,  age  20.  Had  always  been  in  delicate  health.  About  Decem- 
ber, 1892,  noticed  that  the  right  testicle  was  somewhat  enlarged. 
This  steadily  increased,  and  of  late  had  some  pain.  Operation  March 
4th,  1893.  The  testicle  was  about  the  size  of  an  orange.  The 
chord  was  dissected  out  and  ligated  at  the  external  abdominal 
ring.  The  wound  healed  by  first  intention  and  the  patient  left  the 
hospital  in  10  days.  The  growth  was  cystic  degenerated  and  micro- 
scopic examination  showed  it  to  be  a  sarcoma.  Saw  the  patient 
three  months  later.     There  was  no  return  of  the  trouble. 

Case;  IX. — Multiple  Sarcoma. — W.  S.  German;  age  14,  pre- 
viously healthy.  In  1888  had  left  thigh  amputated  at  junction  of 
upper  and  middle  third,  for  tumor  just  above  the  knee.  Stump 
healed  and  the  boy  seemed  to  be  in  good  health.  In  August,  1891, 
broke  his  left  arm  and  bone  did  not  firmly  unite.  In  October,  1891, 
complained  of  pain  in  right  hip,  and  a  swelling  appeared  in  right 
pelvis.  Was  aspirated  and  a  bloody  serum  withdrawn.  In  Decem- 
ber, 1892,  the  left  arm  at  point  of  fracture  commenced  growing  and 
increased  rapidly  in  size.  The  patient  lost  flesh  rapidly  and  suffered 
extreme  pain  requiring  large  hypodermics  of  morphine.  Both 
tumors  rapidly  developed  and  skin  on  the  under  surface  of  arm  be- 
came ulcerated.  July  24,  while  changing  bandage  on  the  arm  a 
sudden  venous  hemorrhage  occurred.  The  blood  ran  in  streams 
from  the  openings  in  the  skin  and  was  controled  only  by  a  tourniquet. 
The  following  morning  arm  was  tightly  bandaged  and    trourniquet 


82 

removed.  Patient  was  very  weak  and  although  no  further  hemorrh- 
age occurred,  patient  suddenly  died  about  noon.  Post  mortem  on 
following  day  showed  the  humerus  entirely  absorbed  and  replaced 
by  a  soft,  cystic  growth.  Arm  measured  13  inches  in  circumference. 
A  soft  gelatinous  tumor  had  developed  in  right  ilium  and  extended 
to  umbilicus.  Microscopic  examination  showed  the  tumor  to  be  a 
myxo  sarcoma. 

Among  the  operations  for  tumors  are  included  three  cases  of 
uaevus.  In  one  case  the  tumor,  about  the  size  of  a  walnut  was 
dissected  out,  the  hemorrhage  stopped  and  the  wound  closed  with- 
out drainage.  Primary  union  took  place  and  there  has  been  no  re- 
turn. In  the  other  two  cases  the  discoloration  was  diffused  over 
the  entire  cheek.  In  one  case  the  Pacquelin  cautery  was  used,  the 
superficial  skin  being  slightly  cauterized,  followed  by  a  sloughing 
of  the  epidermis  ;  in  another  case  the  electro-cautery  was  used  in  a 
similar  manner.     In  both  cases  there  was  considerable  improvement. 

There  wer  j  seven  operations  for  tubercular  glands  of  the  neck. 
In  three  cases  the  glands  were  dissected  out  and  primary  union  fol- 
lowed. In  four  cases  the  glands  were  suppurating  and  were  curet- 
ted, the  wounds  healing  by  granulation. 

Three  operations  were  for  removal  of  the  inguinal  glands,  one 
case  being  a  secondary  deposit  following  carcinoma  of  the  vagina. 
The  other  two  cases  were  for  suppuration,  following  inflammatory 
conditions. 


OPERATIONS    UPON    THE    GENITO-URINARY    ORGANS. 

Forty-six  operations;    20  males,   26   females. 

Case  I.  F.  M.  Suprapubic  Lithotomy ;  Recovery.  German,  age  65. 
Always  been  a  stout,  healthy  man.  In  August,  1891,  complained  of  pain 
in  region  of  the  bladder,  but  required  no  treatment  until  Oct.  25th, 
1892.  The  pain  had  then  become  very  severe  and  the  patient  con- 
sulted Dr.  S.  E.  Kaestlen.  The  symptons  pointed  to  a  vesical 
calculus,  and  the  patient  was  referred  to  a  surgeon  of  this  city.  An 
operation  was  performed  about  the  middle  of  December,  1892,  and  a 


«3 

calculus  about  the  size  of  a  walnut  removed  by  lateral  litlotomy. 
The  patient  suffered  the  most  intense  pain  after  the  operation  and 
left  the  hospital  in  January.  The  pain  continuing,  Dr.  Allen  was 
called  in  consultation  by  Dr.  Kaestlen  March  12th,  1893.  The 
bladder  was  sounded  and  another  calculus  discovered.  The  urine 
was  still  discharging  slightly  through  the  sinus  remaining  from  the 
former  operation.  Operation  was  advised  and  performed  at  Lake- 
side Hospital,  March  18th.  It  was  decided  to  make  the  supra-pubic 
incision.  A  rectal  bag  was  introduced  and  filled  with  6  oz.  of 
water  ;  and  the  bladder  injected  with  four  ounces  of 
water,  pressure  being  kept  upon  the  fistulous  opening.  The 
incision  was  then  made,  the  peritoneum  pushed  upward  and  fixation 
ligatures  introduced  into  the  bladder  before  opening.  The  bladder 
was  then  incised  and  a  uric  acid  calculus  removed,  weighing  64 
grains  and  about  the  size  of  a  thick  lima  bean.  The  bladder  was 
thoroughly  irrigated  and  two  large  catheters  introduced  through  the 
abdominal  opening.  The  bladder  wall  was  tightly  sewed  around 
the  catheters  and  the  ends  of  the  abdominal  incision  brought 
together  with  silk  sutures.  Antiseptic  dressing  was  applied  and 
the  catheters  brought  through  the  bandage  into  bottles  at  the  side 
of  the  patient.  The  patient  stood  the  operation  nicely.  Had  a 
pulse  of  84  at  the  close.  The  bladder  was  washed  every  two  hours 
with  boracic  acid  solution.  The  catheters  were  removed  on  the  fifth 
day  and  a  rubber  drainage  tube  introduced.  Up  to  this  time  there 
had  not  been  a  discharge  of  urine  through  the  abdominal  wound 
sufficient  to  moisten  the  dressing.  The  patient  had  almost  no 
pain  after  the  operation.  Deft  the  hospital  March  29th.  The 
wound  was  entirely  healed  in  about  six  weeks  after  the  operation 
and  the  patient  has  had  no  further  trouble  and  is  now  in  excellent 
health. 

Case  II. — Enucleation  of  the  Testicle  J.  F.  Am.  64.  During  the 
last  two  years  had  had  considerable  pain  in  the  left  testicle-  Had 
worn  a  suspensory  bandage  but  obtained  no  relief     The  paient  was 


»4 

very  much  worried,  and  feared  the  developement  of  a  malignant 
tumor.  At  his  urgent  request,  and  that  of  his  son,  who  was  a 
physician,  an  operation  was  performed.  The  testicle  was  slightly 
enlarged  and  somewhat  softer  than  normal.  A  number  of  small 
cysts  extended  along  the  chord.  The  testicle  was  removed  and  tiie 
wound  healed  by  first  intention.  Patient  has  had  no  trouble  since 
the  operation. 

Case  III. — Enucleation  of  the  Testicle. — Was  a  patient  32  years 
of  age.  About  two  years  ago  contracted  syphilis.  This  was  fol- 
lowed by  deposits  in  the  testicle,  which  soon  ulcerated  and  dis- 
charged through  a  sinus.  The  patient  was  operated  November 
14th.  The  testicle  was  removed  and  wound  packed  with  iodoform 
gauze.  Healing  took  place  by  granulation.  The  testicle  contained 
several  small  abscesses. 

Hydrocele. — Three  operations  ;  three  recoveries.  In  two  cases 
injections  had  been  tried,  but  failed.  In  all  three  cases  the  sac  of 
the  hydrocele  was  dissected  away  and  the  incision  closed 
with  sutures  of  cat-gut,  with  cat-gut  drainage.  Primary  union 
took  place,  and  the  patients  had  no  further  trouble. 

Varicocele. — Two  cases.  Incision  and  ligation  were  performed 
in  both  cases,  with  excision  of  a  portion  of  the  veins.  Both  cases 
healed  by  first  intention. 

Internal  Urethrotmy  for  Stricture. — Two  cases.  Internal  ureth- 
rotomy performed,  so  as  to  allow  the  passage  of  No.  30  French 
sound.  The  bladder  was  washed  out  with  boracic  acid  solution, 
and  a  soft  rubber  catheter  left  in  urethra  for  three  days.  This  was 
then  removed,  and  sounds  were  passed  every  other  day,  until  the 
patients  left  the  hospital.  The  passage  of  sounds  was  continued 
for  several  months. 

External  Urethrotomy. — Two  cases.  The  stricture  in  both 
cases  was  in  the  membranous  portion  of  the  urethra.  Urinary 
infiltration  had  occurred  in    one   case.     A  soft  catheter  was  left  in 


«5 

the  bladder  about  four  days  and  the  passage  of  sounds  carried  out  as 
in  eases  of  internal  urethrotomy. 

Rupture  of  the  Urethra.  One  case.  The  boy  was  a  patient  16 
years  of  age.  Fell  and  struck  on  the  perineum.  The  following  day 
could  not  pass  urine  and  symptoms  of  urinary  infiltration  developed. 
Though  the  skin  was  not  broken,  perineal  section  was  performed, 
and  the  urethra  found  to  have  been  ruptured  entirely  through.  A 
soft  catheter  was  introduced,  and  allowed  to  remain  for  five  days. 
The  passage  of  sounds  was  then  undertaken  but  without  success, 
and  it  has  since  been  necessary  to  anaesthetize  the  patient  in  order 
to  pass  sounds  into  the  posteror  opening. 

Phimosis. — Seven  cases.  The  circular  method  was  employed 
in  six  cases,  the  mucous  membrane  and  skin  being  sewed  with  cat- 
gut sutures  In  one  case  a  boy  18  years  of  age,  in  whom  the  pre- 
puce was  firmly  adherent  to  the  glans,  the  dorsal  incision  was  made, 
and  the  adhesions,  as  far  as  possible,  broken  up. 

Laceration  of  the  Cervix  Uteri. — Five  cases.  In  four  cases, 
uninterrupted  cat  gut  sutures  were  employed  with  satisfactory  re- 
sults. In  one  case  sutures  of  silver  wire  were  used,  with  only  par- 
tial healing.  This  case  was  operated  in  a  private  house  where  the 
antiseptics  could  not  be  thorough^  carried  out. 

Laceratio?i  of  the  Perinaeum.  Seven  cases.  Three  for  recent 
and  four  for  old  lacerations.  In  one  recent  case,  the  laceration 
extended  through  the  sphincter  and  an  inch  up  the  rectum.  The 
operation  was  performed  about  three  hours  after  delivery.  The 
bowel  was  closed  with  fine  cat-gut.  Deep  sutures  of  silver  wire 
were  introduced,  and  etage  sutures  of  fine  cat-gut  continued  to  the 
skin.  In  all  three  recent  cases  union  by  first  intention  took  place. 
Among  the  operations  for  old  lacerations,  three  were  ruptured  into 
the  rectum.  One  case  had  been  previously  twice  operated  without 
success.  The  cicatrix  was  dissected  away  and  the  rent  in  the  bowel 
closed  with  fine  cat-gut.  Deep  sutures  of  silver  wire  were  intro- 
duced.     Superficial  sloughing  took  place,  but  the  sphincter  united, 


86 

and  the  result  is  excellent.  In  another  case  a  laceration,  extend- 
ing into  the  rectum,  had  occured  10  years  previously.  The  patient 
had  no  control  over  her  bowels.  An  operation  similar  to  that  in 
the  preceding  case  was  performed  at  a  private  residence,  where  the 
necessary  antiseptic  precautions  could  not  be  carried  out  and  only 
partial  union  occured.  The  other  two  cases  were  not  ruptured  into 
the  bowel.  They  were  brought  together  with  silver  wire  sutures 
and  union  occured  by  first  intention. 

Amputation  of  the  Cervix:  One  case.  The  cervix  was 
elongated  and  lacerated.  The  patient  had  been  troubled  with 
considerable  discharge.  The  uterus  was  curetted  and  a  wedge 
shaped  amputation  of  the  cervix  performed,  and  the  wound  closed 
with  cat-gut  sutures.     Union  took  place  by  first  intention. 

Dilatation  and  Curetting  of  the  Uterus:  Nine  cases  The  uterus 
was  well  washed  with  distilled  water  and  injections  of  liq.  ferri 
perchloride  used  In  five  cases  the  uterine  cavity  was  tamponed 
with  iodoform  gauze  which  was  removed  about  the  fifth  day. 

Suppurating-  Gland  of  Bartholene:  One  case.  No  history  of  a 
specific  infection.  The  gland  was  about  the  size  of  a  walnut  and 
had  given  considerable  trouble  during  the  last  two  years, 
occasionally  becoming  inflamed  and  very  painful.  Incision  was 
made  through  the  labia,  and  the  suppurating  gland  together 
with  its  duct  removed,  and  the  opening  into  the  vagina 
sewed  with  fine  cat-gut.  The  incision  in  the  skin  was  partially 
closed  with  silk  sutures  and  the  cavity  packed  with  iodoform 
gauze.     The  patient  was  entirely  healed  in  about  ten  days. 

The  following  case  is  worthy  of  special  mention.  C.  D.,  Amer- 
ican, 25  years,  married  five  years.  Menstruated  first  at  14  years. 
Was  regular  but  always  had  severe  pain.  Patient  consulted  Dr. 
Allen  in  March,  1892.  The  vagina  seemed  to  terminate  in  a  blind 
pouch  about  an  inch  in  depth.  The  cervix  could  not  be  seen,  but 
could  be  indistinctly  felt  among  the  deeper  tissues.  An  attempt 
was  made  to  find  an  opening  through  this  membrane  but  without 


*7 

success.  The  patient  was  sent  home  and  instructed  to  present 
herself  for  examination  at  the  commencing  of  her  next  menstrual 
flow.  Patient  returned  April  18th.  A  small  opening  could  be 
seen  from  which  an  occasional  drop  of  bloody  discharge  flowed. 
The  following  day  the  patient  was  anaesthetized  and  a  probe 
introduced  through  the  opening  and  the  membrane  incised  and 
dilated.  This  membrane  was  found  to  be  the  hymen  with  a  small 
opening  and  behind  was  normal  vagina  and  cervix.  Vagina 
tamponed  with  gauze.  The  patient  left  the  hospital  in  about  two 
weeks,  and  returned  to  her  home.  Patient  returned  to  Dr.  Allen 
July  9th.  Had  not  been  unwell  since  the  operation.  Examination 
.showed  the  uteus  somewhat  enlarged.  Pregnancy  was  suspected. 
The  patient  was  delivered  of  an  eight  pound  boy  December  28th,  1892. 


OPERATIONS  UPON  THE  RECTUM. 

Seventeen  cases,  17  recoveries. 

Operations  for  Fistula  :  Seven  cases.  The  fistulous  tracks 
were  laid  open,  curetted  and  packed  with  iodoform  gauze.  Healing 
took  place  by  granulation.  The  bowels  were  moved  on  the  fourth 
daj\     All  the  cases  made  excellent  recoveries. 

Operations  for  Hemorrhoids  :  Five  cases.  Allingham's  opera- 
tion of  ligation  was  performed  in  all  five  cases  with  complete  cures. 

Peri-rectal  Abscesses :  Two  cases.  Incision  and  curetting  of 
the  abscess  cavity  and  the  wound  packed  with  iodoform  gauze. 

Fissure  of  the  Anus:  Two  cases.  In  one  case  the  patient  had 
had  such  severe  attacks  of  pain  that  hypodermic  injections  of  two 
grains  of  morphia  were  required  to  relieve  his  suffering.  In  both 
cases,  the  fissure  was  dissected  out  and  the  wound  closed  with  fine 
cat-gut.  Healing  took  place  by  first  intention  and  the  patients 
have  had  no  return  of  the  trouble. 

Imperforate  Rectum:     One   case.      The  patient,    a   baby  a  few 


days  old.  had  no  movement  of  the  bowels  for  several  days  after 
birth.  Dr.  A.  J.  Cook,  the  attending  physician,  made  an  examina- 
tion, and  found  that  the  rectum  ended  in  a  blind  pouch.  Dr. 
Allen  was  called  in  consultation.  The  sphincter  was  dilated  and 
the  occluded  end  of  the  rectum  opened.  Beyond  this  could  be  felt 
a  mass  coming  down  from  above.  This  was  also  incised,  followed 
by  an  escape  of  faecal  material.  The  bowel  was  washed  out  and 
packed  with  iodoform  gauze.  Daily  dressings  were  made,  and 
iodoform  gauze  introduced.  From  time  to  time  the  rectum  became 
impacted  with  faecal  material  and  required  dilatation.  The  child  is 
now  about  a  year  old  and  perfectly  healthy.  The  child  has  also 
a  congenital  absence  of  three  ribs  on  one  side. 


OPERATIONS  UPON  THE  CHEST. 

Seven  cases.  All  the  operations  were  for  effusions  in  the 
pleural  cavity.       The  following  cases  are  given  in  detail. 

/.  M.  American,  20,  female,  single.  Had  always  been  very 
healthy.  Was  taken  sick  in  April,  1892.  Had  pain  in  the  right  side 
and  was  confined  to  the  bed  about  three  weeks.  The  patient  then 
commenced  to  get  around,  but  did  not  improve  much  and  was  un- 
able to  attend  to  her  duties  as  teacher.  Had  a  persistent  cough 
and  at  times,  some  fever.  During  summer,  chest  was  aspirated  and 
considerable  pus  withdrawn.  In  September  the  patient  grew  much 
worse  and  commenced  expectorating  a  purulent  material.  Dr. 
Allen  first  saw  the  patient  November  17th,  1892.  Patient  was  very 
much  emaciated.  Had  a  rapid  pulse,  and  a  temperature  of  103. 
The  physical  examination  pointed  distinctly  to  a  pyo-pneumo-thorax. 
Operation  was  performed  November  19th  at  Charity  Hospital.  Re- 
sected about  three  inches  of  the  7th  and  8th  ribs  on  the  right  side 
in  the  axillary  line.  The  right  lung  was  tightly  retracted  against 
the  vertebral  column.     The  cavity  was  washed  and  drainage  tubes 


89 

inserted.  After  the  operation  the  patient  slowly  improved.  The 
cavity  was  washed  out  daily  with  boracic  acid  solution.  Patient 
left  the  hospital  December  22nd.  The  sinus  still  remains  open  and 
at  times  the  patient  has  a  fever.  The  cavity  holds  about  a  pint  of 
water.  Patient  is  now  considering  a  second  operation.  In  this 
case  the  radical  operation  had  been  too  long  postponed. 

B.  S.  American;  physician;  31  years;  male;  single.  Always 
had  excellent  health,  and  weighed  about  165  lbs.  In  November, 
1886,  took  a  severe  cold  ;  had  an  attack  of  acute  pleurisy  which 
subsided  in  about  six  days  ;  the  following  month  the  patient  began 
to  cough  and  expectorate  a  purulent  material ;  lost  flesh,  and  at  times 
had  considerable  fever.  In  February,  1887,  patient  was  compelled 
to  discontinue  his  profession,  being  confined  to  his  bed  with  a  temp- 
erature of  103  ;  respiration  30  ;  dullness  over  the  entire  left  side. 
In  March,  1887,  had  a  sudden  expectoration  of  pus  in  large  quan- 
tity. The  chest  was  aspirated  and  five  pints  of  an  odorless  fluid 
with  floculi  of  pus  were  withdrawn.  On  the  following  day  an  in- 
cision was  made  in  the  ninth  intercostal  space,  about  one  inch  in 
front  of  the  axillary  line,  and  a  large  quantity  of  pus  was  dis- 
charged. In  May,  1887,  patient  was  able  to  be  out  of  bed,  but  still 
had  some  fever.  The  amount  of  discharge  daily  diminished,  and 
about  October  8th,  the  wound  closed.  In  November,  1887,  symp- 
toms of  septicaemia  again  appeared  and  thora-centesis  was  again 
performed,  and  8  oz.  of  pus  withdrawn.  At  this  operation  a  por- 
tion of  the  8th  rib  was  resected.  The  fever  subsided,  appetite  re- 
turned, and  in  about  two  weeks  the  patient  was  able  to  be  around. 
The  improvement  continued  as  long  as  free  drainage  was  main- 
tained, but  in  January,  1888,  the  sinus  closed,  when  the  patient 
again  commenced  to  decline.  During  the  following  summer  he  had 
a  hemorrhage,  and  in  September,  1888,  patient  was  again  confined 
to  his  bed.  In  December  an  incision  was  made  through  the  old 
cicatrix  and  drainage  re-established.  In  February,  1889,  the  in- 
cision was  enlarged  and  again  the  following  May.      After  the  last 


9Q 

operation  the  patient  did  not  improve  sufficiently  to  get  ground. 
Suffered  greatly  from  dyspepsia  and  was  exceedingly  nervous.  In 
September,  1889,  portions  of  three  ribs  were  resected,  but  his  condi- 
tion did  not  improve.  In  January,  1890,  a  portion  of  the  5th  rib 
anterior  to  the  shoulder-blade  was  removed,  and  sinues  were  found 
leading  upward  to  a  large  cavity  beneath  the  scapula  The  patient 
by  this  time  was  extremely  emaciated.  Was  taken  South,  but  the 
change  was  followed  only  by  slight  improvement.  In  August,  1891, 
patient  first  consulted  Dr.  Allen.  Portions  of  the  6th,  7th,  8th  and 
9th  ribs  were  resected  and  the  following  November  the  patient  was 
able  t3  get  around  for  the  first  time  in  2^  years.  A  year  later,  in 
November,  1892,  the  patient  again  returned.  A  sinus  remained, 
which  could  be  traced  upward  toward  the  apex  of  the  lung.  His 
gen  jral  condition  was  improved,  but  from  time  to  time  the  sinus 
would  close,  followed  by  symptoms  of  septic  absorption.  Operation 
was  p2rformed  at  Charity  Hospital,  November  29th,  1892.  An  in- 
•  ision  8  inches  in  length  was  made  vertically  and  midway  between 
1  e  spinous  processes  of  the  vertebra  and  the  border  of  the  scapula. 
The  incision  was  carried  through  the  muscles,  and  portions  of  the 
3rd,  4th,  5th,  6th  and  7th  ribs  were  resected  from  the  vertebra  to 
the  border  of  the  scapula-  A  sinus  was  found  leading  upward  to  a 
civity  just  below  the  left  clavicle.  The  sinus  was  enlarged  and  the 
cavity  packed  with  iodoform  gauze.  The  patient  reacted  well  after 
the  operation.  The  tampon  was  removed  on  the  fifth  day  and  the 
wound  daily  irrigated  with  boracic  acid  solution  and  packed  with 
iodoform  gauze.  The  patient  improved  slowly,  had  a  good  appetite 
and  left  the  hospital  about  the  middle  of  February,  1893.  The  patient 
went  South,  and  unfortunately  had  an  attack  of  influenza  and  was 
confined  to  his  bed  six  weeks.  The  patient  has  again  improved 
but  some  slight  discharge  continues.  The  opening  still  remains  to 
the  cavity  below  the  clavicle. 


9i 


OPERATIONS   UPON   THE   HEAD   AND   NECK. 
(not  including  tumors.) 

Twemy-two  cases  with  three  deaths  ;  death  in  two  cases  being 
caused  by  compound  fracture  of  the  skull ;  in  one  case  by  abscess 
of  the  parotid  following  pyemia. 

Operations  upon  the  Skull. — Six  cases. 

Case  I. — The  patient  was  a  Frenchm  an  ;  had  been  a  heavy 
drinker-  Received  a  blow  on  the  head  and  was  brought  to  the 
hospital  two  days  later.  Was  violently  delerious  and  had  a  tem- 
perature ranging  about  103  in  the  axilla.  Incision  was  made  over 
the  seat  of  the  injury  and  a  triangular  portion  of  the  right  parietal 
bone  was  found  to  be  depressed,  and  infection  of  the  wound 
already  to  have  taken  place.  The  wound  was  packed  open  with 
iodoform  gauze,  with  an  antiseptic  dressing  and  ice  bag  on  the 
head.    Patient  steadily  failed  and  died  two  days  after  the  operation. 

Case  II. — A  boy  about  16.  Had  his  head  caught  between  an 
elevator  and  floor,  his  head  stopping  the  elevator.  Was  brought  to 
the  hospital  in  an  unconscious  condition.  The  nasal  eminence 
was  fractured  and  nose  flattened.  Over  the  occiput  there  was  con- 
siderable swelling  and  contusion  of  the  scalp.  The  head  was  shaved, 
and  incision  was  made  over  the  occiput  and  the  clots  of  blood 
turned  out.  No  fracture  was  discovered  in  this  locality.  The  nose 
was  remoulded,  and  the  loose  pieces  of  bone  removed.  The  patient 
made  a  rapid  recovery  and  left  the  hospital  in  about  two  weeks. 

Case  III. — Was  an  extensive  compound  comminuted  fracture 
of  the  skull  with  severe  lacerations  of  the  brain  tissue.  The  patient 
never  regained  consciousness,  and  died  on  the  second  day. 

Case  IV. — Was  struck  by  a  motor  and  received  a  fracture  over 
the  right  ear.  Portions  of  the  temporal  bone  were  depressed,  these 
were  removed  and  the  edges  of  the  bone  cut  away  with  the  rongeur. 
The  wound  healed  by  first  intention  and  the  patient  left  the  hos- 
pital in  about  three  weeks. 


92 

Case  V. — Acquired  Porencephalies. — V.  T.,  American,  20, 
female,  single.  Patient  sent  by  Dr.  W.  N.  Boerstler  of  Peninsula. 
When  six  months  of  age  received  a  blow  upon  the  right  parietal 
bone  and  has  since  had  a  depression  of  the  skull  in  that  region. 
When  two  years  of  age  commenced  having  attacks  of  an  epileptoid 
nature.  These  continued  about  five  years,  gradually  became  less  in 
severity  and  finally  ceasing  to  reappear  again  when  the  patient  was 
14  years  old.  Dr.  Allen  first  saw  the  patient  in  March,  1893,  and 
called  Dr*.  H.  S  Upson  in  consultation.  Patient  was  a  small  deli- 
cate looking  girl,  not  over  intelligent.  In  the  right  parietal  region, 
half  way  between  the  meatus  auditorus  and  vertex  were  two  hori- 
zontal ridges  projecting  above  the  surrounding  skull  about  %  of  an 
inch.  These  ridges  were  1*4  inches  apart  and  between  them  was  a 
slight  depression .  The  ridges  were  four  inches  in  length  ;  the  de- 
pression was  ^y2  inches  in  length  and  its  direction  was  slightly  from 
below  forward  to  above  backwards.  The  central  portion  distinctly 
pulsated  and  was  very  tender  on  pressure.  The  extremities  of  the 
depression  had  no  pulsation  and  presented  a  bony  resistance.  There 
was  marked  loss  of  power  in  the  muscles  of  the  left  arm  and  leg,  with 
contractures,  so  that  the  hand  was  flexed  at  right  angles,  and  could 
not  be  fully  extended.  The  pupils  were  clear,  and  reacted  to  light 
and  were  not  dilated  during  the  attacks.  There  was  no  deviation  of 
the  tongue  or  face.  The  tactile  sensibility  was  unimpaired  over 
the  entire  body.  The  reflex  on  the  right  was  exagerated.  Fundus 
oculi  normal.  The  attacks  varied  in  frequency,  some  days  occurr- 
ing every  hour  or  two.  Patient  was  perfectly  conscious  during  the 
attacks  and  would  cry  out  from  the  severe  pain.  Operation  was 
performed  February  2nd,  1893.  The  day  previous  to  the  operation 
the  scalp  was  shaved  and  an  antiseptic  dressing  applied.  Ether 
was  used  for  anaesthesia.  Scalp  was  again  disinfected,  incised  and 
reflected  from  the  depression.  An  opening  was  found  in  the  skull 
3  inches  in  length  and  1*4  inches  in  width.  This  opening  was  cov- 
ered with  a  very  dense  connective   tissue   membrane,    on    cutting 


93 


Case  V. — Acquired  Porencephalus. — Showing 
Ridges  and  Depression. 


<.'asf,  V.— Acquired  Porencephalia.    Scalp  and  Periosteum  Reflected 
Showing  Opening  in  Skull  Covered  with  a  Dense  Membrane. 


95 

through  which  there  was  an  abundant  discharge  of  serum.  Beneath 
the  parietal  eminence  there  was  a  cavity  extending  antero-posteriorly 
two  inches,  and  transversely  1  ]/2  inches.  Could  see  anteriorly  to 
the  third  ventricle,  and  at  the  bottom  of  the  cavity  the  choroid 
plexus,  optic  thalamus  and  corpus  striatum  could  be  plainly  seen. 
The  pulse  before  the  operation  was  126.  Immediately  on  the  escape 
of  the  serum  it  dropped  to  74,  gradually  coming  up  to  90,  and  then 
fell  again  to  78 ;  was  of  fair  strength  until  the  latter  part  of  the 
operation,  when  it  became  very  weak  necessitating  the  raising  of  the 
foot  of  the  table.  Fifteen  minutes  after  the  operation  the  pulse  was 
128.  The  scalp  was  sutured  with  silkworm-gut,  with  cat-gut  drain- 
age at  the  extremities.  An  antiseptic  dressing  was  applied  and 
held  in  place  by  a  starch  bandage.  On  the  following  day  the  dress- 
ings were  soaked  with  serum  and  were  changed.  The  patient  could 
retain  nothing  on  her  stomach  for  several  days.  The  temperature 
ranged  from  99  to  102  and  on  the  17th  day  went  to  104.  The  pulse 
ranged  from  110  to  128.  The  wound  healed  by  first  intention.  Dur- 
ing the  second  week  there  was  bulging  of  the  scalp  caused  by  an 
accumulation  of  serum  beneath.  This  was  relieved  by  introducing 
a  pair  of  forceps  at  the  angle  of  the  incision  and  allowing  the  serum 
to  escape.  The  attacks  ceased  after  the  operation,  and  the  pain  in 
the  head  was  lessened  except  when  the  cavity  was  fully  distended 
with  serum.  The  patient  regained  strength  very  slowly  and  went 
home  the  early  part  of  April.  Later  she  failed  and  finally  died  ap- 
parently from  asthena.     No  post  mortem  obtained. 

Case  VI. — Craniectomy. — H.  D.,  American,  eight  years  and 
ten  months  ;  male.  The  father  of  the  patient  was  a  peculiar  nervous 
man,  but  well  developed  mentally;  the  mother  a  healthy  woman 
The  patient  has  a  brother  1 1  years  of  age,  a  very  bright  boy.  None 
of  the  family  on  either  side  have  been  idiotic.  The  birth  of  the 
patient  was  normal,  no  instruments  were  used.  The  anterior  fon- 
tainell  was  small  at  birth  and  closed  early.  He  commenced  teeth- 
ing when  four  months  old  and  had  violent  spasms,  which  were  not 


96 

limited  to  any  particular  part  of  the  body.  After  a  convulsion  he 
would  lie  several  hours  in  a  stupor.  The  spasms  continued  until 
the  child  was  two  years  old.  At  this  time  had  talipes  varus  of  the 
right  foot,  but  gradually  outgrew  it.  When  two  years  of  age  he 
knew  many  words  and  could  form  short  sentences,  also  knew  his 
letters,  but  when  about  two  and  one-half  years  old  he  seemed  to 
forget,  and  finally  ceased  speaking.  Patient  never  took  any  nourish- 
ment but  milk  until  he  was  16  months  old,  but  since  that  time  has 
been  a  hearty  eater,  feeds  himself,  and  makes  known  his  likes  and 
dislikes  as  to  what  he  eats.  At  the  time  he  had  spasms,  he  vomited 
a  great  deal,  but  has  not  since.  Has  control  of  his  bowels  and 
bladder  and  makes  known  his  wants.  Has  been  in  the  asylum  at 
Columbus  for  several  years.  The  parents  have  no  control  over 
him;  he  continually  runs  away,  but  does  not  seem  to  have  any  par- 
ticular end  in  view — keeps  on  going  until  he  is  caught  and  brought 
back.  Will  usually  mind  when  commanded  to  do  things,  and 
spoken  to  in  a  stern  manner.  Is  in  continual  motion,  twisting  his 
fingers  and  making  a  clucking  noise  with  his  mouth.  Cries  when 
not  allowed  to  have  his  own  way.  Seems  to  know  his  mother, 
and  will  go  to  her  in  preference  to  strangers.  Is  very  restless  at 
night.  Dr.  Allen  first  saw  the  patient,  May  19th,  1892.  The  head 
of  the  patient  did  not  look  much  under  size,  but  the  mother  stated 
the  family  had,  as  a  rule,  large  heads. 

On  May  20th,  took  the  following  measurements: 

Height  of  patient 51  inches. 

Circumference    of  skull    over   the    occipital 

potuberance  and  just  above  the  e3Tebrows 21  inches. 

Antero-posterior   diameter,    (from    occipital 

protuberance  to  nasal  eminence) 7  5-16  in. 

Bi-parietal  diameter 5  5-8    in. 

Bi-frontal  diameter 4  1-16  in. 

Bi-auricular  diameter 5    inches. 

The  extremities  were  the  same  length  ;  body  well  developed ; 


97 

eyes  light  blue,  but  rather  dull  and  expressionless.  Skull  seemed 
considerably  flattened  posteriorly.  The  family  were  extremely 
anxious  to  have  an  operation  at  any  risk,  and  since  the  child  had 
at  one  time  been  able  to  speak,  it  was  thought  that  the  present 
condition  might  possibly  be  relieved,  although  the  outlook  was  not 
promising.  Operation  was  performed  May  29th,  1892,  at  L,akeside 
Hospital.  The  incision  commenced  at  the  hair  line  over  the  left 
eye,  following  toward  median  line  %  of  an  inch,  and  then  turned 
backward  and  followed  the  general  direction  of  the  sagittal  suture 
9}{  inches,  curving  laterally  at  the  posterior  end.  The  scalp  and 
the  periosteum  were  reflected.  A  button  of  bone  }4  of  an  inch 
in  diameter  was  removed  with  the  trephine,  then  with  Keen's 
rongeur  a  strip  of  bone  }(  of  an  inch  wide  was  removed  the  entire 
length  of  the  incision,  with  short  lateral  cuts  at  each  end.  The 
rongeur  broke  just  as  a  posterior  lateral  cut  was  being  made,  and 
the  operation  was  finished  with  a  hammer  and  chisel.  The  dura 
mater  was  not  opened.  Sewed  the  scalp  with  silkworm-gut 
sutures  and  introduced  cat-gut  drainage  at  each  end  of  the  incision. 
Tho  operation  occupied  29  minutes  from  the  incision  to  the  com- 
pletion of  the  sewing  up  ;  34  minutes  to  the  end  of  the  dressing. 
The  pulse  after  the  operation  was  124.  The  patient  reacted  well, 
and  was  no  more  restless  than  usual.  On  the  following  day  the 
bandage  was  stained  with  a  bloody  discharge,  and  was  changed. 
On  the  seventh  day  stitches  were  removed  and  wound  entirely 
healed  by  first  intention.  The  patient  made  an  uninterrupted 
recovery.  The  family  thought  for  some  time  after  the  operation 
that  he  was  much  more  easily  controlled.  The  journey  home  was 
made  on  a  very  hot  day,  and  two  days  later  the  boy  had  a  spasm 
The  patient  has  again  been  sent  to  the  asylum,  and  at  last  report, 
there  was  little  change  in  his  condition. 

OPERATIONS    FOR    HARK    LIP. 

Three  cases.     Two  operations  were  for  double  hare  lip,  with 
cleft  of  the  palate.     In  one  case  there  was  protrusion  of  the  inter- 


98 

maxillary  bone.     Silkworm-gut  was  used  for  sutures,  and  the  three 
cases  healed  by  first  intention. 

The  remaining  operations  include  the  following  : 

One  for  abscess  of  the  antrum  of  Highmore. 

Two  for  necrosis  of  the  lower  jaw. 

One  for  periostitis. 

One  for  abscess  of  the  parotid. 

One  for  injury  following  an  attempted  suicide. 

Seven  operations  for  removal  of  enlarged  tonsils. 


OPERATIONS  UPON  THE  UPPER  EXTREMITY. 

Twenty-four  cases  with  no  deaths.  Operations  for  palmar 
abscess,  10  cases.  In  each  case  incision  was  made  as  early  as  pos- 
sible, and  free  drainage  established.  The  wounds  were  cleansed 
with  bi-chloride  solution;  tamponed  with  iodoform  gauze  and  a  moist 
dressing  applied.  In  three  cases,  in  spite  of  the  free  drainage,  the 
inflammation  extended  to  the1  fore  arm  and  secondary  operations 
were  performed. 

Phlegmon  of  the  arm  ;  five  cases. 

Case;  I. —  W.  P.  The  patient  had  been  a  heavy  drinker,  and 
his  general  condition  was  very  poor.  Received  a  wound  on  the 
extensor  surface  of  the  fore  arm.  In  a  few  days  the  parts  com- 
menced to  swell,  and  when  brought  to  the  hospital  he  had  a  temp- 
erature of  104,  and  the  entire  arm  was  greatly  swollen.  Free  incis- 
ions were  made,  and  pus  was  found  everywhere  throughout  the 
subcutaneous  tissues.  The  arm  was  poulticed,  and  two  days  after 
the  operation  the  extensor  muscles  of  the  fore  arm  commenced  to 
turn  black  and  slough  away,  leaving  the  bones  exposed.  Amputa- 
tion was  made  at  the  junction  of  the  upper  and  middle  third  of  the 
humerus,  and  at  the  same  time  the  shoulder  joint  was  found  to  be 
full  ot  pus,  and  was  drained.     The  fever  continued  for  several  days, 


99 

when    the    patient    commenced    to    improve,    and   recovery  soon 
followed. 

Case  II. — E.  S.  C.  The  patient  was  a  farmer  and  had  good 
health.  December  11th  cut  his  thumb.  Dr.  Allen  first  saw  the 
patient  the  evening  of  December  15th.  The  entire  arm  and  hand 
were  much  swollen,  and  the  patient  had  a  temperature  of  103.  Was 
delerious  and  in  a  most  critical  condition,  demanding  immediate 
interference.  Ether  was  given  by  the  rapid  method  and  numerous 
incisions  made,  a  more  radical  and  complete  operation  being  left 
until  the  next  morning.  The  thumb  was  found  to  be  gangrenous, 
and  was  amputated  through  the  metacarpal  bone.  Pus  was  found 
throughout  the  hand,  dissecting  along  both  flexor  and  extensor 
tendons  of  the  fingers.  Pus  was  also  found  throughout  the  subcu- 
taneous tissue  of  the  arm,  extending  to  the  shoulder.  Incisions 
were  made,  and  drainage  tubes  introduced-  The  arm  was  poulticed, 
and  for  a  time,  improved-  The  latter  part  of  December  the  tem- 
perature again  commenced  to  go  up,  necessitating  another  operation 
with  opening  of  some  of  the  deeper  tissues  of  the  hand.  At  this  oper- 
ation a  bullet  was  found  which  had  been  shot  into  the  palm  of  the 
hand  16  years  previouly,  and  had  never  given  rise  to  any  trouble. 
The  patient  went  on  to  recovery,  though  the  hand  was  seriously 
damaged. 

K.  S- — Osteoclasty  for  malunion  of  the  Radius.  Patient  was  a 
delicate  boy  13  years  of  age.  On  July  7th  sustained  a  Colles  frac- 
ture of  right  radius.  This  was  followed  by  considerable  swelling 
and  the  fracture  was  not  discovered.  Dr.  Allen  first  saw  the  patient 
July  26th.  The  swelling  had  subsided  end  the  deformity  was 
plainly  visible.  Operation  was  performed  July  28th.  An  anaes- 
thetic was  given  and  the  bone  refractured.  The  arm  was  kept  in 
splints  for  about  three  weeks,  and  then  dressed  with  adhesive  plas- 
ter.    A  perfect  result  was  obtained. 

The  remaining  operations  include  one  operation  for  gun  shot 
wound  of  the  hand,  with   extraction  of  the  ball ;  one  operation  for 


IOO 


abscess  of  the  elbow  joint  following  injury ;  and  six  amputations  of 
the  fore  arm  and  hand. 


OPERATIONS  UPON  THE -LOWER  EXTREMITY. 

Thirty-two  cases  with  two  deaths,  the  causes  of  death  being: 

One  following  double  amputation  for  injury,  in  an  old  lady  81 
years  old. 

One  a  secondary  amputation  of  the  leg,  on  account  of  septi- 
caemia, resulting  from  compound  fracture. 

Amputations  :  Fourteen  cases,  three  being  double  amputations 
following  injury.     The  amputations  include  the  following: 

Five  amputations  of  the  leg. 

Three  amputations  of  the  thigh. 

Two  Pirogoff  amputations. 

Four  amputations  through  the  metatarsus. 

Operations  for  Club  Foot :  Three  cases.  In  one  case  of  talipes 
varus  occuring  in  a  little  girl  three  years  of  age,  a  wedge  shaped 
piece  of  bone  was  removed  at  the  articulation  of  the  cuboid  and  as- 
tragalus. At  the  same  time  the  plantar  fascia  was  divided.  At  a 
subsequent  operation,  tenotomy  was  performed  upon  the  tendo- 
Achilles.  The  patient  made  a  good  recovery  and  has  but  a  slight 
deformity  of  the  foot.  In  another  case,  contracture  of  the  tendo- 
Achilles  followed  a  fracture  of  the  lower  end  of  the  tibia  and  fibula, 
with  slight  displacement  of  the  bone  backward.  Relieved  by  ten- 
otomy. 

Cares  of  the  Tibia  :  Two  cases.  In  one  case  the  head  of  the 
tibia  was  involved  ;  the  diseased  bone  was  removed  with  curett 
and  the  bone  packed  with  iodoform  gauze.  A  discharge  continued 
for  about  four  months  when  the  sinus  closed.  In  the  other  case  the 
entire  epiphysis  of  the  lower  extremitity  of  the  bone  was  involved. 
The  diseased  bone  was  curetted,  and  the  patient  made  a  perfect 
recovery . 


IOI 

Necrosis  of  the  Femur  :  Two  cases.  In  both  cases  the  shaft  of 
the  bone  was  opened  and  the  dead  portions  removed.  In  one  case 
a  small  sinus  still  remains. 

Operations  for  Abscess  :  Three  cases.  In  one  case  the  patient 
was  an  old  man  59  years  of  age.  A  large  tubucular  abscess  in- 
volved the  inner  and  flexor  surface  of  the  thigh ;  was  incised  and 
drained  and  the  patient  made  a  complete  recovery.  Another  case 
was  an  abscess  of  the  hip  joint,  following  pyemia.  About  two 
quarts  of  pus  were  taken  from  the  tissues  around  the  hip  joint. 
The  patient  died  of  septicaeima  six  days  after  the  operation.  This 
is  the  same  case  reported  as  having  died  with  abscess  of  the  parotid. 
The  third  case  was  one  of  abcesses  of  the  leg  and  knee.  At  the 
first  operation  the  parts  were  thoroughly  drained,  but  the  patient 
gradually  grew  worse,  and  two  weeks  later  an  amputation  was  per- 
formed at  the  middle  of  the  thigh.  The  ankle  and  knee  joints  were 
found  to  be  full  of  pus  and  the  articular  ends  of  the  bone  completely 
destroyed.      Patient  made  good  recovery. 

F.  B  — Osteotomy  for  Malunion  of  the  Femur.  The  patient  was 
a  healthy  boy  13  years  of  age.  In  November,  1890,  broke  his  femur 
about  three  inches  above  the  knee  joint.  Dr.  Allen  first  saw  the 
patient  June  28th,  1892.  There  was  considerable  deformity  at  the 
point  of  fracture.  Operated  July  1st.  Incision  was  made  along  the 
outer  side  of  the  thigh,  over  the  fracture.  The  bone  was  divided 
with  a  chisel ;  the  incision  in  the  skin  sewed  with  cat-gut  and  an 
antiseptic  drecsing  and  splints  applied.  The  patient  remained  in 
bed  five  weeks,  and  was  then  allowed  to  go  around  on  crutches. 
An  excellent  result  was  obtained,  with  only  a  half  inch  shortening. 

The  remaining  operations  were  as  follows  : 

One  excision  for  Hygroma  of  the  knee. 

One  aspiration  for  effusion  in  the  knee  joint. 

One  operation  for  removal  of  a  needle  in  the  thigh. 

One,operation  for  periostitis  of  tha  tibia. 


102 


One  operation  for  an  extensive  phlegmon  of  the  foot  following 
injury. 

One  operation  for  horny  growths  of  the  nails. 


MISCELLANEOUS  OPERATIONS. 
Ten  operations. 

Thierschs,  Transplantation:  Seven  cases.  Two  of  these  opera- 
tions were  for  extensive  burns  of  the  thigh,  involving  the  entire 
extensor  service.     All  the  operations  were  successful. 

Tetanus.     Two  cases.     One  death,  one  recovery. 

Case  I- — H.  F.,  American,  27,  a  healthy  man.  June  14th, 
while  working  in  the  field,  punctured  his  foot  with  a  harrow.  The 
wound  -healed,  but  some  tenderness  remained.  Eight  days  after 
the  injury,  commenced  to  have  severe  pain  in  the  scar.  The  wound 
opened,  and  discharged  a  thin  bloody  serum.  On  the  ninth  day, 
had  symptoms  of  trismus,  and  on  the  tenth  day  the  symptoms  were 
much  aggravated  and  the  patient  had  violent  spasms  with  opistho- 
tonus. Heavy  doses  of  bromide  and  chloral  were  given,  but  with  no 
benefit  Dr.  Allen  first  saw  the  patient  on  the  11th  day  The 
wound  was  curetted  and  an  antiseptic  dressing  applied.  The  patient 
died  on  the  12th  day.  Cultures  made  from  the  wound  showed  the 
bacilli  of  tetanus  to  be  present. 

Case  II. — H.  N.  August  1st  punctured  the  flexor  surface  of 
the  wrist  with  an  ice  pick.  The  wound  gave  him  no  trouble  at  the 
time.  On  the  third  day  noticed  that  the  scar  was  tender.  On  the 
morning  of  the  fourth  day,  on  rising,  found  that  he  could  open  his 
jaws  only  about  one-fourth  of  an  inch.  The  wound  had  opened, 
and  was  discharging  a  thin  bloody  serum.  The  surrounding  skin 
was  redneded,  and  the  inflamed  lymphatics  could  be  traced  up  the 
arm.  The  wound  was  curetted,  and  an  antiseptic  dressing  applied. 
The  patient  was  put  to  bed  and  given  heavy  doses  of  bromide  and 


iQ3 

chloral.  The  following  day  the  inflammation  around  the  wound 
had  somewhat  subsided.  The  muscles  of  the  jaw  gradually  relaxed, 
and  in  four  days  all  symptoms  of  lockjaw  disappeared. 


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